Fillable INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

Fill Online, Printable, Fillable, Blank INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas) Form

Use Fill to complete blank online CITY OF PASADENA, TEXAS (TX) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

On average this form takes 32 minutes to complete

The INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas) form is 2 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 128 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Pasadena, Texas

BROWSE CITY OF PASADENA, TEXAS (TX) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INDIVIDUAL ELIGIBILITY FORM (City of Pasadena, Texas)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document