Fillable INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

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INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

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INDIVIDUAL ELIGIBILITY FORM
For Community Development Block Grant Programs
Revised 10/2019
In accordance with 24 CFR 570.506, agencies must acquire information to determine client eligibility as well as
for general reporting purposes. To participate in this program that is funded by Federal Funds, you must fill out
this form completely and accurately.
CLIENT ELIGIBILITY INFORMATION CDBG Program Name:
Name
Address
City
State
Zip
Home Phone
Gender
Male Female Transgender
Is this client a
minor?
Yes No
If yes, Name of
Guardian
Is client a Citizen or Permanent U.S.
resident?
Yes No
TX Drivers / ID No.
Is the client a resident of the City of Pasadena?
YES
NO
Disabled
Yes No
Elderly
Yes No
Residency Proof Documentation Provided
(Example: driver’s license / ID Card / Bill)
Ethnicity
Hispanic
Non-Hispanic
Is Client a Veteran
Yes No
Race
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
Total # of Household Members
________
Gross Annual Household Income
$ _________________
Adults (Age 18 & older)
______
Children (Age 17 & under)
______
Elderly (Age 62 & older)
______
Proof of Income Documentation Provided
(Example: SS Award Letter / W-2 form / Check Stubs)
Head of Household
Male
Female
Transgender
I certify that, to the best of my knowledge and belief, all the information on and attached is true, correct,
complete, and provided in good faith. I understand that false or fraudulent information on, or attached to this
request may be grounds for being ineligible to receive the assistance requested and may be punishable by a
fine and/or imprisonment. I understand that any information I give may be investigated.
Print Name
Signature
Date
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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INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

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Completed 25 February 2021

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