City of Rio Rancho
Community Development Block Grant Program (CDBG-CV)
Small Business Assistance Program
Income Verification Form - For Job Retention
Dear : Business: ______________________________________
Your employer has received assistance through the City of Rio Rancho 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 provided through the City of Rio Rancho’s Small Business Assistance
Program. Please be assured that this information will remain confidential and will be used only to meet the record keeping
requirements of the U.S. Department of Housing and Urban Development, which is providing the CDBG funds to help
retain your job.
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 Rio Rancho Financial Services Department, 3200 Civic Center Circle, Suite 300, Rio Rancho, NM 87144,
sgonzales@rrnm.gov. Thank you for your cooperation.
Please circle below the number of people in your household, including yourself:
1 2 3 4 5 6 7 8
$38,750 $44,250 $49,800 $55,300 $59,750 $64,150 $68,600 $73,000
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Was your total household income during the last 12 months higher or lower than the amount below the number you
circled? The dollar amounts represent annual household income.
Please circle one: HIGHER OR LOWER
Describe any employer paid benefits you receive as an employee:__________________________________
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Please circle the appropriate race category and Hispanic ethnicity if applicable. (optional):
1. White 6. Black/African American
2. Asian 7. American Indian/ Alaskan Native
3. Native Hawaiian/Other Pacific Islander 8. American Indian/Alaskan Native& White
4.Asian & White 9. Black/African American & White
5. American Indian/Alaskan Native & Black/African American 10. Other Multi Racial
Hispanic ethnicity if appropriate: Hispanic/Not Hispanic Female Headed Household? Yes ______ No ______
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.
_________________________________________ ____________________________________________
Employee Signature Date
