INDIVIDUAL ELIGIBILITY FORM
For Community Development Block Grant Programs
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:
Is client a Citizen or Permanent U.S.
Is the client a resident of the City of Pasadena?
Residency Proof Documentation Provided
(Example: driver’s license / ID Card / Bill)
Native & White
Native & Black
Total # of Household Members
Gross Annual Household Income
Children (Age 17 & under)
Proof of Income Documentation Provided
(Example: SS Award Letter / W-2 form / Check Stubs)
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.
For Subrecipient Staff Only
Is Client Approved/Eligible for Services?
National Objective Met: YES NO
National Objective 570.208
Benefit to Low & Moderate Income Persons
Abused children Battered Spouses Elderly Disabled Homeless Illiterate