INCOME VERIFICATION FORM - For Job Retention
DATE : Business:_____________________________________
Your employer has received assistance through the City of Massillon to maintain/retain the business and
associated job(s), including your job. We are asking your cooperation in completing this form for record keeping
purposes to verify both the job retention and income benefits being provided through the City of Massillon's
small business assistance program.
As soon as you have completed the information listed below, you may submit it directly to your employer or
return it to the City of Massillon Community Development Department, 151 Lincoln Way East, Massillon OH
44646 or email to firstname.lastname@example.org. Thank you for your cooperation.
Full Name (print please):
Are you a resident of the City of Massillon?
Please select the number of people in your household, including yourself:
☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8
Was your total household income during the last 12 months higher or lower than the amount indicated below
The dollar amount represents annual household income.
☐ Higher ☐ Lower
$37,050 $42,350 $47,650 $52,900 $57,150 $61,400 $65,600 $69,850
Describe any employer paid benefits you receive as an employee:
Please identify the appropriate race category and Hispanic ethnicity if applicable (optional):
American Indian/Alaskan Native
American Indian/Alaskan Native & Black/African American
Black/African American & White
American Indian/Alaskan Native & White
Native Hawaiian/ Other Pacific Islander
Hispanic ethnicity if appropriate
By signing below, I hereby certify that the information contained on this form is accurate and complete to the
best of my knowledge, under penalty of law and verifiable by federal government representatives.
COVID-19 CDBG EMERGENY BUSINESS ASSISTANCE LOAN PROGRAM