COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG)
AGENCY NAME: ___________NEIGHBORHOOD DEVELOPMENT FOUNDATION_________
PROJECT NUMBER: ___________ __________________________________________________
The __NEIGHBORHOOD DEVELOPMENT FOUNDATION _ has received federal funding
assistance from the City of New Orleans, Division of Housing and Neighborhood Development and State
of Louisiana Department of Social Services. City funds are made available by the U.S. Department of
Housing and Neighborhood Development (HUD) through the Community Development Block program.
These organizations primary objective is to make certain eligible services available to persons of very
low, low and moderate income. In order to help us to monitor our progress toward this goal, we request
your assistance in completing the following:
S.S. #: _______________________________________________________________________________
(Household means all person (s) who occupy a housing unit. The occupants may be single family, one person
living alone, two or more families living together, or any other group of related or unrelated person who share
Please check the space in each column that most accurately describes your household size and gross income.
FAMILY/HOUSEHOLD SIZE GROSS INCOME
__________ 1 ______$ 0.00 - 49,440.00 ______$20,420.00
__________ 2 ______$49,440.00 - 56,520.00 ______$27,380.00
__________ 3 ______$56,520.00 - 63,600.00 ______$34,340.00
__________ 4 ______$63,600.00 - 70,560.00 ______$41,300.00
__________ 5 ______$70,560.00 - 76,320.00 ______$48,260.00
__________ 6 ______$76,320.00 - 81,960.00 ______$55,220.00
__________ 7 ______$81,960.00 - 87,600.00 ______$62,180.00
__________ 8 ______$87,600.00 - 93,240.00 ______$69,140.00
__________ OVER 8 ______$93,240.00 - OVER ______$6,690 Each Add.
(Only Clients 50%)
I certify that all of the information provided herein is true and correct and that all household income is reported. I
understand that this information is subject to verification by the City of New Orleans, State Department of Social
Services and the U.S. Department of Housing and Urban Development (HUD) or its agent for the purpose of
determining my eligibility for participation in the programs funded by these governmental agencies that is
administered by ______
NDF_______. I further understand that deliberate misrepresentation of the required
information may subject me to prosecution under applicable Local, State, and Federal laws.
SIGNATURE _________________________________________ DATE _______________________
NOTE: In addition to this questionnaire, a copy of support documentation such as most recent
check stub, welfare card, current income tax return, etc. will be required.
Census Tract Number (s) ______________________________________________________________
OFFICE USE ONLY
NOTE: Put an "X" next to your selected household size and income below