Household Income Verification Form | Wood County Rec

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Household Income Verification Form

Household Income Verification Form

INSTRUCTIONAL BASKETBALL CLINIC.pdf

Applicant Section:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Income Status:

Find the size of your family on the grid below, then select the income level that applies to your family size. If ‘above’ is selected for your appropriate family size, you do not income qualify for the program. Income guidelines subject to change annually per U.S. Department of Housing and Urban Development. Last Updated: 6/15/2022

Select Family Size:

Select Income:

Select Income:

Select Income:

Select Income:

Select Income:

Select Income:

Select Income:

Select Income:

Do you live in a Female- Headed Household?

Yes

No

Do you have a disability?

Yes

No

Please select one ethnic background:

Hispanic

Not Hispanic

Prefer not to Disclose

Please check the most appropriate race group:

White

Asian

Black/African American

Amer. Indian/Alaskan Native

Native Hawaiian/ Other Pacific Islander

Asian & White

Amer. Indian/Alaskan Native & White

Other Multi-Racial

Black/African Amer. & White

Amer. Indian/Alaskan Native & Black/African Amer.

Note:

“Any false statement made knowingly and willingly may subject the signer to penalties under Section 1010 of Title 18 of the United States Code.”

Signature (of Applicant):

Date

MM slash DD slash YYYY

Signature of Company Representative

Date

MM slash DD slash YYYY

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Contact us at: woodcountyrec@gmail.com

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