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FORMULARIO DE ELEGIBILIDAD (City of Pasadena, Texas)

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FORMULARIO DE ELEGIBILIDAD
For Community Development Block Grant Programs
Revised 10/2019
De acuerdo con 24 CFR 570.506, las agencias deben adquirir información para determiner la elegibilidad del
cliente, así como para propósitos de informes generals. Para participar en este programa que está financiado por
fondos federales, debe completer este formulario de manera complete y precisa.
INFORMACION DEL CLIENTE Nombre del Programa:
Nombre
Dirección
Ciudad
Estado
Código Postal
# de Casa
Genero
Masculino Hembra Transgenero
¿Es este cliente un
menor?
Sí No
¿Nombre del
tutor?
¿Ciudadano o residente permanente de
los Estados Unidos?
Sí No
Licencia de conducir de
Texas o ID de Texas
¿Es el cliente residente de la Cuidad de Pasadena?
Si
No
Discapacitado
Sí No
Mayor
Sí No
Prueba de Residencia
(Example: driver’s license / ID Card / Bill)
Etnicidad
Hispanic
Non-Hispanic
Veterano
Sí No
Raza
Black / African
American
White
Asian
American Indian/
Alaskan Native
Other /Multi
Racial
American Indian/Alaskan
Native & White
American Indian/Alaskan
Native & Black
Native Hawaiian/
Other Pacific Islander
Asian
& White
Black/African
American & White
# de miembros del hogar
________
Ingreso Bruto Total del Hogar
$ ___________
Adultos (Age 18 & older)
______
Ninos (Age 17 & under)
______
Mayor (Age 62 & older)
______
Comprobante de Documentación de Ingresos
(Example: SS Award Letter / W-2 form / Check Stubs)
Jefe de Hogar
Masculino
Hembra
Transgenero
Yo certifico según mi conocimiento y entender que toda la información dada y adjunta es correcta, complete y
proporcionada de Buena fe. Entiendo que el proveer información falsa o fraudulenta en o adjunto puede ser motive
para determinarme inelegible para recibir asistencia solicitada y puedo ser penado con una multa y/o encarcelamiento.
Entiendo que cualquier información dada puede ser investigada.
Nombre
Firma
Fecha
For Subrecipient Staff Only
Is Client Approved/Eligible for Services?
YES NO
National Objective Met: YES NO
National Objective 570.208
Benefit to Low & Moderate Income Persons
LMI Area
Benefit
LMI Limited
Clientele
LMI Housing
Benefit
LMI Jobs
Creation
Client Income Level
0 – 30 %
31 – 50 %
51 – 80 %
LMILC - Presumed Benefit
Abused children Battered Spouses Elderly Disabled Homeless Illiterate
Name of Reviewer:
Signature:
Date:
GENERAL
CLIENT INFO
INCOME
STAFF ONLY
SIGN HERE
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FORMULARIO DE ELEGIBILIDAD (City of Pasadena, Texas)

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Completed 25 February 2021

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