Household Income Verification Form Household Income Verification Form Applicant Section:Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail(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: 6/15/2022Select Family Size:12345678Select Income:$0 –$14,250$14,251 - $23,700$23,701 - $28,440$28,441 - $37,900AboveSelect Income:$0 - $16,250$16,251 - $27,050$27,051 - $32,460$32,461 - $43,300AboveSelect Income:$0 - $18,300$18,301 - $30,450$30,451 - $36,540$36,541 - $48,700AboveSelect Income:$0 - $20,300$20,301 - $33,800$33,801 - $40,560$40,561 - $54,100AboveSelect Income:$0 - $21,950$21,951 - $36,550$36,551 - $43,860$43,861 - $58,450AboveSelect Income:$0 - $23,550$23,551 - $39,250$39,251 - $47,100$47,101 - $62,800AboveSelect Income:$0 - $25,200$25,201 - $41,850$41,851-$50,340$50,341 - $67,100AboveSelect Income:$0 - $26,800$26,801 - $44,650$44,651 – $53,580$53,581 - $71,450AboveDo 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): Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Signature of Company Representative Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
