Fillable MITCHELL COUNTY CDBG-CV INSTRUCTIONS FOR COMPLETING EMPLOYEE CERTIFICATION (Mitchell County, Kansas)

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MITCHELL COUNTY CDBG-CV INSTRUCTIONS FOR COMPLETING EMPLOYEE CERTIFICATION (Mitchell County, Kansas)

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MITCHELL COUNTY CDBG-CV
INSTRUCTIONS FOR COMPLETING EMPLOYEE CERTIFICATION FORM
1. An Employee Certification Form must be completed and signed by each employee retained
during the specified time period of the CDBG project. During the project, the KDOC
representatives will compare payroll listings to the Employee Certification Forms. Any
employee without a certification form will not qualify as a job created by the project or will be
classified as a non-LMI job.
2. Prior to giving the form to the employee, the company should fill in their date of
employment/hire. The company should also fill in the exact job title, since many times the
employee does not know that information.
3. Owners, LLC members or corporation stockholders do not need to be included in the employee
count unless a sole proprietorship without employees.
4. The employee MUST complete the other information, including a check in the column of the
income section. The income is the total gross family income for the past 12 months or the
2019 Tax Return whichever is less. The easiest way to get this is to have them use the gross
income they reported on their last income tax return. PLEASE NOTE: The employee is not
required to fill out the personal information on the certification form if they choose not to do so.
5. Make sure the employee signs and dates the form.
6. Please return the completed and signed form to NCRPC.
7. If the employee feels more comfortable, it is acceptable to have them place in a sealed envelope.
Questions contact:
North Central Regional Planning Commission
Keegan Bailey, Housing Assistant
P.O. Box 565
109 N. Mill St.
Beloit, KS 67420
Telephone: (785) 738-2218
Fax: (785) 738-2185
kbailey@nckcn.com
Community Development Block Grant 89 Economic Development Grantee Handbook
STATE OF KANSAS
DEPARTMENT OF COMMERCE
EMPLOYEE CERTIFICATION FORM
Name of Company:
Project #:
Date Employed:
Family Income-Total income from all family members during the prior year from all sources. This includes but is
not limited to wages, salary, interest, dividends, royalties, and farm income.
In the left column below, check off the box that indicates your family size. Using the income limits on the line
corresponding to your family size, check off the appropriate income box on the right side.
FAMILY
SIZE
Section 1:INCOME LIMITS
A
(30%)
B
(50%)
1
TO
TO
Income below Column A
Income between Column A & B
Income between Column B & C
Income Above Column C
2
TO
TO
3
TO
TO
4
TO
TO
5
TO
TO
6
TO
TO
7
TO
TO
8+
TO
TO
RACE/ETHNICITY & DISABILITY STATUS
Do you have a handicap or disability?
Yes No
Are you Hispanic?
Yes No
Are you a female head of household?
Yes No
RACE
White
American Indian/Alaskan Native & White
Black/African American
Asian & White
Asian
Black/African American & White
American Indian/Alaskan Native
American Indian/Alaskan Native & Black/African American
Native Hawaiian/Other Pacific Islander
Other
Does your employer offer a health care plan for this job?
Yes No
Were you unemployed before taking this job?
Yes No
To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the
city/county or the State of Kansas. I also certify that I am authorized to work in the United States and can produce
evidence of work authorization.
Job Title
Date
Print Name
Signature Required
Number of hours worked per week _____________
14,050
23,400
17,240
26,750
21,720
30,100
26,200
33,400
30,680
36,100
35,160
38,750
39,640
41,450
44,100
44,100
37,450
42,800
48,150
53,450
57,750
62,050
66,300
70,600
Mitchell Co. 20-CV-045
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MITCHELL COUNTY CDBG-CV INSTRUCTIONS FOR COMPLETING EMPLOYEE CERTIFICATION (Mitchell County, Kansas)

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Completed 17 August 2021

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