Fillable COVID-19 Microenterprise Stabilization Program (MicroE) (Town of Bristol)

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COVID-19 Microenterprise Stabilization Program (MicroE) (Town of Bristol)

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U.S.A. forms for Town of Bristol

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COVID-19 Microenterprise Stabilization Program (MicroE)
Family Income Self-Certification Form
Instructions:
Your eligibility to participate in this program is determined in part by the size of your family and your family
income. A FAMILY is defined as a group of persons residing together, and any dependent children living
outside of the home. Family types include, but are not limited to: a family with or without children, an elderly
family; a near-elderly family; a disabled family; a displaced family; a co-habitating couple; a multi-generational
family. An individual living in a housing unit that contains no other person(s) related to him/her is considered
to be a one-person family for this purpose.
INCOME is defined as the total annual gross income of all family members 18+ years old. All sources of
income during calendar year 2019 must be counted. Income includes all money coming into the family from all
persons aged 18 or older. Wages, self-employment wages, business income, TANF, alimony, Social Security
benefits, pensions, child support, and regular gifts of money from friends, family or a church must be included.
Money earned from providing services, and interest from bank accounts or investments must be included.
WARNING: The information provided on this form is subject to verification by the Town of Bristol,
State of Rhode Island, and HUD at any time. Title 18, Section 1001 of the U.S. Code states that a person
who knowingly and willingly makes a false, fictitious, or fraudulent statement or representation, or
conceals a material fact, shall be subject to fines and up to 5 years of imprisonment.
Page 1 of 2
MicroE Family Income Self Certification Form
Form #6 For internal use
Date Rec’d ___/___/_____
Applicant/Business:
_______________________
Page 2 of 2
MicroE Family Income Self Certification Form
COVID-19 Microenterprise Stabilization Program (MicroE)
Family Income Self-Certification Form
Family Member Information:
Total persons in your family, including yourself:
In the chart below, provide the requested information for each adult family member. Then calculate the total
annual gross family income.
Name
Age
Relationship
to you
Annual Income ($$)
Source(s) of Income
yourself:
Total Annual
Gross Family
Income:
REQUIRED: For each member of the family over age 18 filing separately, attach a copy of IRS Form 1040
for Tax Year 2018, or 2019 if available. This is necessary to complete your application.
I certify that all information is true and complete, in accordance with the instructions on page 1. I made no
misrepresentation, nor did I omit any pertinent information. I fully understand that it is a federal crime,
punishable by fine or imprisonment, or both, to knowingly make any false statements when applying for CDBG
assistance, as applicable under the provisions of Title 18, United States Code, Section 1001, et seq.
Signature of Applicant: Date:
Printed Name:
Home Address:
Business Name:
Form #6 For internal use
Date Rec’d ___/___/_____
Applicant/Business:
_______________________
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COVID-19 Microenterprise Stabilization Program (MicroE) (Town of Bristol)

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Completed 9 February 2021

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