7. Low- to Moderate-Income Representative (Optional)
Do you represent an agency that serves low- and moderate-income populations?
Yes No
Does your household qualify as low- or moderate-income, based upon the 2015 HUD income limits listed below?
(Income must be at or below amount listed for your household size)
Yes No
8. Bilingual Representative (Optional)
Is the applicant bilingual and does the applicant represent a non-English speaking population?
Yes No
2017 HUD Income Limits - Montgomery County, Ohio
Household Size
1 2 3 4 5 6 7 8
Annual Income
$36,800 $42,050 $47,300 $52,550 $56,800 $61,000 $65,200 $69,400
* Income Category: Low-Income (80% of Area Median Income)
If so, please list the agency below:
If so, which language and which population?
9. Additional Information (Optional)
Please include any additional information you feel is relevant to this application:
I hereby submit my application for membership to the Community and Neighborhood Development Advisory Board. By providing an
electronic signature (type your name) below I certify that the information submitted within this application is true and correct to the best
of my knowledge.
Date
Enter Electronic Signature
Return to the attention of:
City of Dayton
Erin Jeffries
Dept. of Planning & Community Development
101 West Third Street
Dayton, OH 45402
E-mail: erin.jeffries@daytonohio.gov
Telephone: (937) 333-3863
Fax #: (937) 333-4281
click to sign
signature
click to edit
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