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2020 EMPLOYEE SELF CERTIFICATION FORMSTABLE OF CONTENTSDirections: Press the “CTRL” key on the computer keyboard and click on a county name below to automatically advance to the Employee Self Certification Form for that county. TOC \o "1-1" \n \p " " \h \z \u 2020 Adams County2020 Ashland County2020 Barron County2020 Bayfield County2020 Brown County2020 Buffalo County2020 Burnett County2020 Calumet County2020 Chippewa County2020 Clark County2020 Columbia County2020 Crawford County2020 Dane County2020 Dodge County2020 Door County2020 Douglas County2020 Dunn County2020 Eau Claire County2020 Florence County2020 Fond du Lac County2020 Forest County2020 Grant County2020 Green County2020 Green Lake County2020 Iowa County2020 Iron County2020 Jefferson County2020 Juneau County2020 Kenosha County2020 Kewaunee County2020 La Crosse County2020 Lafayette County2020 Langlade County2020 Lincoln County2020 Manitowoc County2020 Marathon County2020 Marinette County2020 Marquette County2020 Menominee County2020 Milwaukee County2020 Monroe County2020 Oconto County2020 Oneida County2020 Outagamie County2020 Ozaukee County2020 Pepin County2020 Pierce County2020 Polk County2020 Portage County2020 Price County2020 Racine County2020 Richland County2020 Rock County2020 Rusk County2020 Sauk County2020 Sawyer County2020 Shawano County2020 Sheboygan County2020 Taylor County2020 Trempealeau County2020 Vernon County2020 Vilas County2020 Walworth County2020 Washburn County2020 Washington County2020 Waukesha County2020 Waupaca County2020 Waushara County2020 Winnebago County2020 Wood CountyTHIS PAGE IS INTENTIONALLY LEFT BLANK4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Adams CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Adams CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Ashland CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Ashland CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Barron CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Barron CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Bayfield CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Bayfield CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Brown CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,300 $17,301 - $28,850 $28,851 - $46,100_____Greater than $46,1002 $0 - $19,800 $19,801 - $32,950 $32,951 - $52,700_____Greater than $52,7003 $0 - $22,250 $22,251 - $37,050 $37,051 - $59,300_____Greater than $59,3004 $0 - $26,200 $26,201 - $41,150 $41,151 - $65,850_____Greater than $65,8505 $0 - $30,680 $30,681 - $44,450 $44,451 - $71,150_____Greater than $71,1506 $0 - $35,160 $35,161 - $47,750 $47,751 - $76,400_____Greater than $76,4007 $0 - $39,640 $39,641 - $51,050 $51,051 - $81,700_____Greater than $81,7008 or more $0 - $44,120 $44,121 - $54,350 $54,351 - $86,950_____Greater than $86,950Source: 2020 HUD low-moderate income level limits for Brown CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Buffalo CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Buffalo CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Burnett CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Burnett CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Calumet CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $18,150 $18,151 - $30,250 $30,251 - $48,400_____Greater than $48,4002 $0 - $20,750 $20,751 - $34,600 $34,601 - $55,300_____Greater than $55,3003 $0 - $23,350 $23,351 - $38,900 $38,901 - $62,200_____Greater than $62,2004 $0 - $26,200 $26,201 - $43,200 $43,201 - $69,100_____Greater than $69,1005 $0 - $30,680 $30,681 - $46,700 $46,701 - $74,650_____Greater than $74,6506 $0 - $35,160 $35,161 - $50,150 $50,151 - $80,200_____Greater than $80,2007 $0 - $39,640 $39,641 - $53,600 $53,601 - $85,700_____Greater than $85,7008 or more $0 - $44,120 $44,121 - $57,050 $57,051 - $91,250_____Greater than $91,250Source: 2020 HUD low-moderate income level limits for Calumet CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Chippewa CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,100 $16,101 - $26,850 $26,851 - $42,950_____Greater than $42,9502 $0 - $18,400 $18,401 - $30,700 $30,701 - $49,100_____Greater than $49,1003 $0 - $21,720 $21,721 - $34,550 $34,551 - $55,250_____Greater than $55,2504 $0 - $26,200 $26,201 - $38,350 $38,351 - $61,350_____Greater than $61,3505 $0 - $30,680 $30,681 - $41,450 $41,451 - $66,300_____Greater than $66,3006 $0 - $35,160 $35,161 - $44,500 $44,501 - $71,200_____Greater than $71,2007 $0 - $39,640 $39,641 - $47,600 $47,601 - $76,100_____Greater than $76,1008 or more $0 - $44,120 $44,121 - $50,650 $50,651 - $81,000_____Greater than $81,000Source: 2020 HUD low-moderate income level limits for Chippewa CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Clark CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Clark CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Columbia CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,200 $17,201 - $28,650 $28,651 - $45,850_____Greater than $45,8502 $0 - $19,650 $19,651 - $32,750 $32,751 - $52,400_____Greater than $52,4003 $0 - $22,100 $22,101 - $36,850 $36,851 - $58,950_____Greater than $58,9504 $0 - $26,200 $26,201 - $40,900 $40,901 - $65,450_____Greater than $65,4505 $0 - $30,680 $30,681 - $44,200 $44,201 - $70,700_____Greater than $70,7006 $0 - $35,160 $35,161 - $47,450 $47,451 - $75,950_____Greater than $75,9507 $0 - $39,640 $39,641 - $50,750 $50,751 - $81,200_____Greater than $81,2008 or more $0 - $44,120 $44,121 - $54,000 $54,001 - $86,400_____Greater than $86,400Source: 2020 HUD low-moderate income level limits for Columbia CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Crawford CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Crawford CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Dane CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $21,050 $21,051 - $35,050 $35,051 - $54,950_____Greater than $54,9502 $0 - $24,050 $24,051 - $40,050 $40,051 - $62,800_____Greater than $62,8003 $0 - $27,050 $27,051 - $45,050 $45,051 - $70,650_____Greater than $70,6504 $0 - $30,050 $30,051 - $50,050 $50,051 - $78,500_____Greater than $78,5005 $0 - $32,500 $32,501 - $54,100 $54,101 - $84,800_____Greater than $84,8006 $0 - $35,160 $35,161 - $58,100 $58,101 - $91,100_____Greater than $91,1007 $0 - $39,640 $39,641 - $62,100 $62,101 - $97,350_____Greater than $97,3508 or more $0 - $44,120 $44,121 - $66,100 $66,101 - $103,650_____Greater than $103,650Source: 2020 HUD low-moderate income level limits for Dane CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Dodge CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,300 $16,301 - $27,150 $27,151 - $43,400_____Greater than $43,4002 $0 - $18,600 $18,601 - $31,000 $31,001 - $49,600_____Greater than $49,6003 $0 - $21,720 $21,721 - $34,900 $34,901 - $55,800_____Greater than $55,8004 $0 - $26,200 $26,201 - $38,750 $38,751 - $62,000_____Greater than $62,0005 $0 - $30,680 $30,681 - $41,850 $41,851 - $67,000_____Greater than $67,0006 $0 - $35,160 $35,161 - $44,950 $44,951 - $71,950_____Greater than $71,9507 $0 - $39,640 $39,641 - $48,050 $48,051 - $76,900_____Greater than $76,9008 or more $0 - $44,120 $44,121 - $51,150 $51,151 - $81,850_____Greater than $81,850Source: 2020 HUD low-moderate income level limits for Dodge CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Door CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,650 $15,651 - $26,100 $26,101 - $41,750_____Greater than $41,7502 $0 - $17,900 $17,901 - $29,800 $29,801 - $47,700_____Greater than $47,7003 $0 - $21,720 $21,721 - $33,550 $33,551 - $53,650_____Greater than $53,6504 $0 - $26,200 $26,201 - $37,250 $37,251 - $59,600_____Greater than $59,6005 $0 - $30,680 $30,681 - $40,250 $40,251 - $64,400_____Greater than $64,4006 $0 - $35,160 $35,161 - $43,250 $43,251 - $69,150_____Greater than $69,1507 $0 - $39,640 $39,641 - $46,200 $46,201 - $73,950_____Greater than $73,9508 or more $0 - $44,120 $44,121 - $49,200 $49,201 - $78,700_____Greater than $78,700Source: 2020 HUD low-moderate income level limits for Door CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Douglas CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,150 $16,151 - $26,900 $26,901 - $43,050_____Greater than $43,0502 $0 - $18,450 $18,451 - $30,750 $30,751 - $49,200_____Greater than $49,2003 $0 - $21,720 $21,721 - $34,600 $34,601 - $55,350_____Greater than $55,3504 $0 - $26,200 $26,201 - $38,400 $38,401 - $61,450_____Greater than $61,4505 $0 - $30,680 $30,681 - $41,500 $41,501 - $66,400_____Greater than $66,4006 $0 - $35,160 $35,161 - $44,550 $44,551 - $71,300_____Greater than $71,3007 $0 - $39,640 $39,641 - $47,650 $47,651 - $76,200_____Greater than $76,2008 or more $0 - $44,120 $44,121 - $50,700 $50,701 - $81,150_____Greater than $81,150Source: 2020 HUD low-moderate income level limits for Douglas CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Dunn CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,050 $15,051 - $25,050 $25,051 - $40,050_____Greater than $40,0502 $0 - $17,240 $17,241 - $28,600 $28,601 - $45,800_____Greater than $45,8003 $0 - $21,720 $21,721 - $32,200 $32,201 - $51,500_____Greater than $51,5004 $0 - $26,200 $26,201 - $35,750 $35,751 - $57,200_____Greater than $57,2005 $0 - $30,680 $30,681 - $38,650 $38,651 - $61,800_____Greater than $61,8006 $0 - $35,160 $35,161 - $41,500 $41,501 - $66,400_____Greater than $66,4007 $0 - $39,640 $39,641 - $44,350 $44,351 - $70,950_____Greater than $70,9508 or more $0 - $44,120 $44,121 - $47,200 $47,201 - $75,550_____Greater than $75,550Source: 2020 HUD low-moderate income level limits for Dunn CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Eau Claire CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,100 $16,101 - $26,850 $26,851 - $42,950_____Greater than $42,9502 $0 - $18,400 $18,401 - $30,700 $30,701 - $49,100_____Greater than $49,1003 $0 - $21,720 $21,721 - $34,550 $34,551 - $55,250_____Greater than $55,2504 $0 - $26,200 $26,201 - $38,350 $38,351 - $61,350_____Greater than $61,3505 $0 - $30,680 $30,681 - $41,450 $41,451 - $66,300_____Greater than $66,3006 $0 - $35,160 $35,161 - $44,500 $44,501 - $71,200_____Greater than $71,2007 $0 - $39,640 $39,641 - $47,600 $47,601 - $76,100_____Greater than $76,1008 or more $0 - $44,120 $44,121 - $50,650 $50,651 - $81,000_____Greater than $81,000Source: 2020 HUD low-moderate income level limits for Eau Claire CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Florence CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Florence CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Fond du Lac CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,650 $16,651 - $27,750 $27,751 - $44,350_____Greater than $44,3502 $0 - $19,000 $19,001 - $31,700 $31,701 - $50,700_____Greater than $50,7003 $0 - $21,720 $21,721 - $35,650 $35,651 - $57,050_____Greater than $57,0504 $0 - $26,200 $26,201 - $39,600 $39,601 - $63,350_____Greater than $63,3505 $0 - $30,680 $30,681 - $42,800 $42,801 - $68,450_____Greater than $68,4506 $0 - $35,160 $35,161 - $45,950 $45,951 - $73,500_____Greater than $73,5007 $0 - $39,640 $39,641 - $49,150 $49,151 - $78,600_____Greater than $78,6008 or more $0 - $44,120 $44,121 - $52,300 $52,301 - $83,650_____Greater than $83,650Source: 2020 HUD low-moderate income level limits for Fond du Lac CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Forest CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Forest CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Grant CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Grant CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Green CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,600 $16,601 - $27,650 $27,651 - $44,250_____Greater than $44,2502 $0 - $19,000 $19,001 - $31,600 $31,601 - $50,600_____Greater than $50,6003 $0 - $21,720 $21,721 - $35,550 $35,551 - $56,900_____Greater than $56,9004 $0 - $26,200 $26,201 - $39,500 $39,501 - $63,200_____Greater than $63,2005 $0 - $30,680 $30,681 - $42,700 $42,701 - $68,300_____Greater than $68,3006 $0 - $35,160 $35,161 - $45,850 $45,851 - $73,350_____Greater than $73,3507 $0 - $39,640 $39,641 - $49,000 $49,001 - $78,400_____Greater than $78,4008 or more $0 - $44,120 $44,121 - $52,150 $52,151 - $83,450_____Greater than $83,450Source: 2020 HUD low-moderate income level limits for Green CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Green Lake CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Green Lake CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Iowa CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,500 $16,501 - $27,500 $27,501 - $44,000_____Greater than $44,0002 $0 - $18,850 $18,851 - $31,400 $31,401 - $50,250_____Greater than $50,2503 $0 - $21,720 $21,721 - $35,350 $35,351 - $56,550_____Greater than $56,5504 $0 - $26,200 $26,201 - $39,250 $39,251 - $62,800_____Greater than $62,8005 $0 - $30,680 $30,681 - $42,400 $42,401 - $67,850_____Greater than $67,8506 $0 - $35,160 $35,161 - $45,550 $45,551 - $72,850_____Greater than $72,8507 $0 - $39,640 $39,641 - $48,700 $48,701 - $77,900_____Greater than $77,9008 or more $0 - $44,120 $44,121 - $51,850 $51,851 - $82,900_____Greater than $82,900Source: 2020 HUD low-moderate income level limits for Iowa CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Iron CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Iron CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Jackson CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Jackson CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Jefferson CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,100 $16,101 - $26,850 $26,851 - $42,950_____Greater than $42,9502 $0 - $18,400 $18,401 - $30,650 $30,651 - $49,050_____Greater than $49,0503 $0 - $21,720 $21,721 - $34,500 $34,501 - $55,200_____Greater than $55,2004 $0 - $26,200 $26,201 - $38,300 $38,301 - $61,300_____Greater than $61,3005 $0 - $30,680 $30,681 - $41,400 $41,401 - $66,250_____Greater than $66,2506 $0 - $35,160 $35,161 - $44,450 $44,451 - $71,150_____Greater than $71,1507 $0 - $39,640 $39,641 - $47,500 $47,501 - $76,050_____Greater than $76,0508 or more $0 - $44,120 $44,121 - $50,600 $50,601 - $80,950_____Greater than $80,950Source: 2020 HUD low-moderate income level limits for Jefferson CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Juneau CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Juneau CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Kenosha CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,350 $16,351 - $27,200 $27,201 - $43,550_____Greater than $43,5502 $0 - $18,650 $18,651 - $31,100 $31,101 - $49,750_____Greater than $49,7503 $0 - $21,720 $21,721 - $35,000 $35,001 - $55,950_____Greater than $55,9504 $0 - $26,200 $26,201 - $38,850 $38,851 - $62,150_____Greater than $62,1505 $0 - $30,680 $30,681 - $42,000 $42,001 - $67,150_____Greater than $67,1506 $0 - $35,160 $35,161 - $45,100 $45,101 - $72,100_____Greater than $72,1007 $0 - $39,640 $39,641 - $48,200 $48,201 - $77,100_____Greater than $77,1008 or more $0 - $44,120 $44,121 - $51,300 $51,301 - $82,050_____Greater than $82,050Source: 2020 HUD low-moderate income level limits for Kenosha CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Kewaunee CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,300 $17,301 - $28,850 $28,851 - $46,100_____Greater than $46,1002 $0 - $19,800 $19,801 - $32,950 $32,951 - $52,700_____Greater than $52,7003 $0 - $22,250 $22,251 - $37,050 $37,051 - $59,300_____Greater than $59,3004 $0 - $26,200 $26,201 - $41,150 $41,151 - $65,850_____Greater than $65,8505 $0 - $30,680 $30,681 - $44,450 $44,451 - $71,150_____Greater than $71,1506 $0 - $35,160 $35,161 - $47,750 $47,751 - $76,400_____Greater than $76,4007 $0 - $39,640 $39,641 - $51,050 $51,051 - $81,700_____Greater than $81,7008 or more $0 - $44,120 $44,121 - $54,350 $54,351 - $86,950_____Greater than $86,950Source: 2020 HUD low-moderate income level limits for Kewaunee CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 La Crosse CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,150 $16,151 - $26,900 $26,901 - $43,050_____Greater than $43,0502 $0 - $18,450 $18,451 - $30,750 $30,751 - $49,200_____Greater than $49,2003 $0 - $21,720 $21,721 - $34,600 $34,601 - $55,350_____Greater than $55,3504 $0 - $26,200 $26,201 - $38,400 $38,401 - $61,450_____Greater than $61,4505 $0 - $30,680 $30,681 - $41,500 $41,501 - $66,400_____Greater than $66,4006 $0 - $35,160 $35,161 - $44,550 $44,551 - $71,300_____Greater than $71,3007 $0 - $39,640 $39,641 - $47,650 $47,651 - $76,200_____Greater than $76,2008 or more $0 - $44,120 $44,121 - $50,700 $50,701 - $81,150_____Greater than $81,150Source: 2020 HUD low-moderate income level limits for La Crosse CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Lafayette CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Lafayette CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Langlade CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Langlade CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Lincoln CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,050 $15,051 - $25,100 $25,101 - $40,150_____Greater than $40,1502 $0 - $17,240 $17,241 - $28,700 $28,701 - $45,900_____Greater than $45,9003 $0 - $21,720 $21,721 - $32,300 $32,301 - $51,650_____Greater than $51,6504 $0 - $26,200 $26,201 - $35,850 $35,851 - $57,350_____Greater than $57,3505 $0 - $30,680 $30,681 - $38,750 $38,751 - $61,950_____Greater than $61,9506 $0 - $35,160 $35,161 - $41,600 $41,601 - $66,550_____Greater than $66,5507 $0 - $39,640 $39,641 - $44,500 $44,501 - $71,150_____Greater than $71,1508 or more $0 - $44,120 $44,121 - $47,350 $47,351 - $75,750_____Greater than $75,750Source: 2020 HUD low-moderate income level limits for Lincoln CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Manitowoc CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,650 $15,651 - $26,050 $26,051 - $41,650_____Greater than $41,6502 $0 - $17,850 $17,851 - $29,750 $29,751 - $47,600_____Greater than $47,6003 $0 - $21,720 $21,721 - $33,450 $33,451 - $53,550_____Greater than $53,5504 $0 - $26,200 $26,201 - $37,150 $37,151 - $59,450_____Greater than $59,4505 $0 - $30,680 $30,681 - $40,150 $40,151 - $64,250_____Greater than $64,2506 $0 - $35,160 $35,161 - $43,100 $43,101 - $69,000_____Greater than $69,0007 $0 - $39,640 $39,641 - $46,100 $46,101 - $73,750_____Greater than $73,7508 or more $0 - $44,120 $44,121 - $49,050 $49,051 - $78,500_____Greater than $78,500Source: 2020 HUD low-moderate income level limits for Manitowoc CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Marathon CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,600 $16,601 - $27,650 $27,651 - $44,250_____Greater than $44,2502 $0 - $19,000 $19,001 - $31,600 $31,601 - $50,600_____Greater than $50,6003 $0 - $21,720 $21,721 - $35,550 $35,551 - $56,900_____Greater than $56,9004 $0 - $26,200 $26,201 - $39,500 $39,501 - $63,200_____Greater than $63,2005 $0 - $30,680 $30,681 - $42,700 $42,701 - $68,300_____Greater than $68,3006 $0 - $35,160 $35,161 - $45,850 $45,851 - $73,350_____Greater than $73,3507 $0 - $39,640 $39,641 - $49,000 $49,001 - $78,400_____Greater than $78,4008 or more $0 - $44,120 $44,121 - $52,150 $52,151 - $83,450_____Greater than $83,450Source: 2020 HUD low-moderate income level limits for Marathon CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Marinette CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Marinette CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Marquette CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Marquette CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Menominee CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Menominee CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Milwaukee CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,650 $17,651 - $29,350 $29,351 - $46,950_____Greater than $46,9502 $0 - $20,150 $20,151 - $33,550 $33,551 - $53,650_____Greater than $53,6503 $0 - $22,650 $22,651 - $37,750 $37,751 - $60,350_____Greater than $60,3504 $0 - $26,200 $26,201 - $41,900 $41,901 - $67,050_____Greater than $67,0505 $0 - $30,680 $30,681 - $45,300 $45,301 - $72,450_____Greater than $72,4506 $0 - $35,160 $35,161 - $48,650 $48,651 - $77,800_____Greater than $77,8007 $0 - $39,640 $39,641 - $52,000 $52,001 - $83,150_____Greater than $83,1508 or more $0 - $44,120 $44,121 - $55,350 $55,351 - $88,550_____Greater than $88,550Source: 2020 HUD low-moderate income level limits for Milwaukee CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Monroe CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,200 $15,201 - $25,250 $25,251 - $40,400_____Greater than $40,4002 $0 - $17,350 $17,351 - $28,850 $28,851 - $46,200_____Greater than $46,2003 $0 - $21,720 $21,721 - $32,450 $32,451 - $51,950_____Greater than $51,9504 $0 - $26,200 $26,201 - $36,050 $36,051 - $57,700_____Greater than $57,7005 $0 - $30,680 $30,681 - $38,950 $38,951 - $62,350_____Greater than $62,3506 $0 - $35,160 $35,161 - $41,850 $41,851 - $66,950_____Greater than $66,9507 $0 - $39,640 $39,641 - $44,750 $44,751 - $71,550_____Greater than $71,5508 or more $0 - $44,120 $44,121 - $47,600 $47,601 - $76,200_____Greater than $76,200Source: 2020 HUD low-moderate income level limits for Monroe CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Oconto CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Oconto CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Oneida CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Oneida CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Outagamie CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $18,150 $18,151 - $30,250 $30,251 - $48,400_____Greater than $48,4002 $0 - $20,750 $20,751 - $34,600 $34,601 - $55,300_____Greater than $55,3003 $0 - $23,350 $23,351 - $38,900 $38,901 - $62,200_____Greater than $62,2004 $0 - $26,200 $26,201 - $43,200 $43,201 - $69,100_____Greater than $69,1005 $0 - $30,680 $30,681 - $46,700 $46,701 - $74,650_____Greater than $74,6506 $0 - $35,160 $35,161 - $50,150 $50,151 - $80,200_____Greater than $80,2007 $0 - $39,640 $39,641 - $53,600 $53,601 - $85,700_____Greater than $85,7008 or more $0 - $44,120 $44,121 - $57,050 $57,051 - $91,250_____Greater than $91,250Source: 2020 HUD low-moderate income level limits for Outagamie CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Ozaukee CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,650 $17,651 - $29,350 $29,351 - $46,950_____Greater than $46,9502 $0 - $20,150 $20,151 - $33,550 $33,551 - $53,650_____Greater than $53,6503 $0 - $22,650 $22,651 - $37,750 $37,751 - $60,350_____Greater than $60,3504 $0 - $26,200 $26,201 - $41,900 $41,901 - $67,050_____Greater than $67,0505 $0 - $30,680 $30,681 - $45,300 $45,301 - $72,450_____Greater than $72,4506 $0 - $35,160 $35,161 - $48,650 $48,651 - $77,800_____Greater than $77,8007 $0 - $39,640 $39,641 - $52,000 $52,001 - $83,150_____Greater than $83,1508 or more $0 - $44,120 $44,121 - $55,350 $55,351 - $88,550_____Greater than $88,550Source: 2020 HUD low-moderate income level limits for Ozaukee CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Pepin CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Pepin CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Pierce CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $21,700 $21,701 - $36,200 $36,201 - $54,950_____Greater than $54,9502 $0 - $24,800 $24,801 - $41,400 $41,401 - $62,800_____Greater than $62,8003 $0 - $27,900 $27,901 - $46,550 $46,551 - $70,650_____Greater than $70,6504 $0 - $31,000 $31,001 - $51,700 $51,701 - $78,500_____Greater than $78,5005 $0 - $33,500 $33,501 - $55,850 $55,851 - $84,800_____Greater than $84,8006 $0 - $36,000 $36,001 - $60,000 $60,001 - $91,100_____Greater than $91,1007 $0 - $39,640 $39,641 - $64,150 $64,151 - $97,350_____Greater than $97,3508 or more $0 - $44,120 $44,121 - $68,250 $68,251 - $103,650_____Greater than $103,650Source: 2020 HUD low-moderate income level limits for Pierce CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Polk CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Polk CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Portage CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,500 $16,501 - $27,500 $27,501 - $44,000_____Greater than $44,0002 $0 - $18,850 $18,851 - $31,400 $31,401 - $50,250_____Greater than $50,2503 $0 - $21,720 $21,721 - $35,350 $35,351 - $56,550_____Greater than $56,5504 $0 - $26,200 $26,201 - $39,250 $39,251 - $62,800_____Greater than $62,8005 $0 - $30,680 $30,681 - $42,400 $42,401 - $67,850_____Greater than $67,8506 $0 - $35,160 $35,161 - $45,550 $45,551 - $72,850_____Greater than $72,8507 $0 - $39,640 $39,641 - $48,700 $48,701 - $77,900_____Greater than $77,9008 or more $0 - $44,120 $44,121 - $51,850 $51,851 - $82,900_____Greater than $82,900Source: 2020 HUD low-moderate income level limits for Portage CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Price CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Price CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Racine CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,150 $16,151 - $26,950 $26,951 - $43,050_____Greater than $43,0502 $0 - $18,450 $18,451 - $30,800 $30,801 - $49,200_____Greater than $49,2003 $0 - $21,720 $21,721 - $34,650 $34,651 - $55,350_____Greater than $55,3504 $0 - $26,200 $26,201 - $38,450 $38,451 - $61,500_____Greater than $61,5005 $0 - $30,680 $30,681 - $41,550 $41,551 - $66,450_____Greater than $66,4506 $0 - $35,160 $35,161 - $44,650 $44,651 - $71,350_____Greater than $71,3507 $0 - $39,640 $39,641 - $47,700 $47,701 - $76,300_____Greater than $76,3008 or more $0 - $44,120 $44,121 - $50,800 $50,801 - $81,200_____Greater than $81,200Source: 2020 HUD low-moderate income level limits for Racine CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Richland CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Richland CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Rock CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Rock CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Rusk CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Rusk CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 St. Croix CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $21,700 $21,701 - $36,200 $36,201 - $54,950_____Greater than $54,9502 $0 - $24,800 $24,801 - $41,400 $41,401 - $62,800_____Greater than $62,8003 $0 - $27,900 $27,901 - $46,550 $46,551 - $70,650_____Greater than $70,6504 $0 - $31,000 $31,001 - $51,700 $51,701 - $78,500_____Greater than $78,5005 $0 - $33,500 $33,501 - $55,850 $55,851 - $84,800_____Greater than $84,8006 $0 - $36,000 $36,001 - $60,000 $60,001 - $91,100_____Greater than $91,1007 $0 - $39,640 $39,641 - $64,150 $64,151 - $97,350_____Greater than $97,3508 or more $0 - $44,120 $44,121 - $68,250 $68,251 - $103,650_____Greater than $103,650Source: 2020 HUD low-moderate income level limits for St. Croix CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Sauk CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,250 $15,251 - $25,400 $25,401 - $40,600_____Greater than $40,6002 $0 - $17,400 $17,401 - $29,000 $29,001 - $46,400_____Greater than $46,4003 $0 - $21,720 $21,721 - $32,650 $32,651 - $52,200_____Greater than $52,2004 $0 - $26,200 $26,201 - $36,250 $36,251 - $58,000_____Greater than $58,0005 $0 - $30,680 $30,681 - $39,150 $39,151 - $62,650_____Greater than $62,6506 $0 - $35,160 $35,161 - $42,050 $42,051 - $67,300_____Greater than $67,3007 $0 - $39,640 $39,641 - $44,950 $44,951 - $71,950_____Greater than $71,9508 or more $0 - $44,120 $44,121 - $47,850 $47,851 - $76,600_____Greater than $76,600Source: 2020 HUD low-moderate income level limits for Sauk CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Sawyer CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Sawyer CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Shawano CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Shawano CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Sheboygan CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,400 $15,401 - $25,700 $25,701 - $41,100_____Greater than $41,1002 $0 - $17,600 $17,601 - $29,400 $29,401 - $47,000_____Greater than $47,0003 $0 - $21,720 $21,721 - $33,050 $33,051 - $52,850_____Greater than $52,8504 $0 - $26,200 $26,201 - $36,700 $36,701 - $58,700_____Greater than $58,7005 $0 - $30,680 $30,681 - $39,650 $39,651 - $63,400_____Greater than $63,4006 $0 - $35,160 $35,161 - $42,600 $42,601 - $68,100_____Greater than $68,1007 $0 - $39,640 $39,641 - $45,550 $45,551 - $72,800_____Greater than $72,8008 or more $0 - $44,120 $44,121 - $48,450 $48,451 - $77,500_____Greater than $77,500Source: 2020 HUD low-moderate income level limits for Sheboygan CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Taylor CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Taylor CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Trempealeau CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,100 $15,101 - $25,200 $25,201 - $40,250_____Greater than $40,2502 $0 - $17,250 $17,251 - $28,800 $28,801 - $46,000_____Greater than $46,0003 $0 - $21,720 $21,721 - $32,400 $32,401 - $51,750_____Greater than $51,7504 $0 - $26,200 $26,201 - $35,950 $35,951 - $57,500_____Greater than $57,5005 $0 - $30,680 $30,681 - $38,850 $38,851 - $62,100_____Greater than $62,1006 $0 - $35,160 $35,161 - $41,750 $41,751 - $66,700_____Greater than $66,7007 $0 - $39,640 $39,641 - $44,600 $44,601 - $71,300_____Greater than $71,3008 or more $0 - $44,120 $44,121 - $47,500 $47,501 - $75,900_____Greater than $75,900Source: 2020 HUD low-moderate income level limits for Trempealeau CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Vernon CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Vernon CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Vilas CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Vilas CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Walworth CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $16,600 $16,601 - $27,650 $27,651 - $44,250_____Greater than $44,2502 $0 - $19,000 $19,001 - $31,600 $31,601 - $50,600_____Greater than $50,6003 $0 - $21,720 $21,721 - $35,550 $35,551 - $56,900_____Greater than $56,9004 $0 - $26,200 $26,201 - $39,500 $39,501 - $63,200_____Greater than $63,2005 $0 - $30,680 $30,681 - $42,700 $42,701 - $68,300_____Greater than $68,3006 $0 - $35,160 $35,161 - $45,850 $45,851 - $73,350_____Greater than $73,3507 $0 - $39,640 $39,641 - $49,000 $49,001 - $78,400_____Greater than $78,4008 or more $0 - $44,120 $44,121 - $52,150 $52,151 - $83,450_____Greater than $83,450Source: 2020 HUD low-moderate income level limits for Walworth CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Washburn CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Washburn CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Washington CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,650 $17,651 - $29,350 $29,351 - $46,950_____Greater than $46,9502 $0 - $20,150 $20,151 - $33,550 $33,551 - $53,650_____Greater than $53,6503 $0 - $22,650 $22,651 - $37,750 $37,751 - $60,350_____Greater than $60,3504 $0 - $26,200 $26,201 - $41,900 $41,901 - $67,050_____Greater than $67,0505 $0 - $30,680 $30,681 - $45,300 $45,301 - $72,450_____Greater than $72,4506 $0 - $35,160 $35,161 - $48,650 $48,651 - $77,800_____Greater than $77,8007 $0 - $39,640 $39,641 - $52,000 $52,001 - $83,150_____Greater than $83,1508 or more $0 - $44,120 $44,121 - $55,350 $55,351 - $88,550_____Greater than $88,550Source: 2020 HUD low-moderate income level limits for Washington CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Waukesha CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,650 $17,651 - $29,350 $29,351 - $46,950_____Greater than $46,9502 $0 - $20,150 $20,151 - $33,550 $33,551 - $53,650_____Greater than $53,6503 $0 - $22,650 $22,651 - $37,750 $37,751 - $60,350_____Greater than $60,3504 $0 - $26,200 $26,201 - $41,900 $41,901 - $67,050_____Greater than $67,0505 $0 - $30,680 $30,681 - $45,300 $45,301 - $72,450_____Greater than $72,4506 $0 - $35,160 $35,161 - $48,650 $48,651 - $77,800_____Greater than $77,8007 $0 - $39,640 $39,641 - $52,000 $52,001 - $83,150_____Greater than $83,1508 or more $0 - $44,120 $44,121 - $55,350 $55,351 - $88,550_____Greater than $88,550Source: 2020 HUD low-moderate income level limits for Waukesha CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Waupaca CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,100 $15,101 - $25,150 $25,151 - $40,250_____Greater than $40,2502 $0 - $17,250 $17,251 - $28,750 $28,751 - $46,000_____Greater than $46,0003 $0 - $21,720 $21,721 - $32,350 $32,351 - $51,750_____Greater than $51,7504 $0 - $26,200 $26,201 - $35,900 $35,901 - $57,450_____Greater than $57,4505 $0 - $30,680 $30,681 - $38,800 $38,801 - $62,050_____Greater than $62,0506 $0 - $35,160 $35,161 - $41,650 $41,651 - $66,650_____Greater than $66,6507 $0 - $39,640 $39,641 - $44,550 $44,551 - $71,250_____Greater than $71,2508 or more $0 - $44,120 $44,121 - $47,400 $47,401 - $75,850_____Greater than $75,850Source: 2020 HUD low-moderate income level limits for Waupaca CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Waushara CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $14,900 $14,901 - $24,800 $24,801 - $39,700_____Greater than $39,7002 $0 - $17,240 $17,241 - $28,350 $28,351 - $45,350_____Greater than $45,3503 $0 - $21,720 $21,721 - $31,900 $31,901 - $51,000_____Greater than $51,0004 $0 - $26,200 $26,201 - $35,400 $35,401 - $56,650_____Greater than $56,6505 $0 - $30,680 $30,681 - $38,250 $38,251 - $61,200_____Greater than $61,2006 $0 - $35,160 $35,161 - $41,100 $41,101 - $65,750_____Greater than $65,7507 $0 - $39,640 $39,641 - $43,900 $43,901 - $70,250_____Greater than $70,2508 or more $0 - $44,120 $44,121 - $46,750 $46,751 - $74,800_____Greater than $74,800Source: 2020 HUD low-moderate income level limits for Waushara CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Winnebago CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $17,000 $17,001 - $28,300 $28,301 - $45,300_____Greater than $45,3002 $0 - $19,400 $19,401 - $32,350 $32,351 - $51,750_____Greater than $51,7503 $0 - $21,850 $21,851 - $36,400 $36,401 - $58,200_____Greater than $58,2004 $0 - $26,200 $26,201 - $40,400 $40,401 - $64,650_____Greater than $64,6505 $0 - $30,680 $30,681 - $43,650 $43,651 - $69,850_____Greater than $69,8506 $0 - $35,160 $35,161 - $46,900 $46,901 - $75,000_____Greater than $75,0007 $0 - $39,640 $39,641 - $50,100 $50,101 - $80,200_____Greater than $80,2008 or more $0 - $44,120 $44,121 - $53,350 $53,351 - $85,350_____Greater than $85,350Source: 2020 HUD low-moderate income level limits for Winnebago CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. 4762500-38100UGLG Name: __________________Business Name: ________________00UGLG Name: __________________Business Name: ________________2020 Wood CountySTATE OF WISCONSINCOMMUNITY DEVELOPMENT BLOCK GRANTEMPLOYEE SELF CERTIFICATIONDear Employee:(Enter Business name) is collecting the following information as a result of participating in the U.S. Housing and Urban Development’s (HUD) Community Development Block Grant (CDBG) program. To meet federal regulations, (Enter Business Name) is required to collect statistical data on your family income, race/ethnicity, and employment status. This information is reported to HUD and eventually used by the U.S. Congress to measure the effectiveness of the CDBG program. Your name and personal information will be kept private, and your income, race and unemployment status information only shared with the federal government anonymously. It is only through your cooperation that your community can benefit from this federal program. INSTRUCTIONS:Please answer questions 1, 2, and 3, then sign and date the form certifying the information is correct. Your information can only be accepted if the form is completed in full. Please indicate your current family income in the following table. “Family” means all related persons in your household.Please Circle # of Persons in your FamilyFAMILY INCOME CATEGORY Please check your family income in the same row as the number of persons in your family.ABCD1 $0 - $15,500 $15,501 - $25,800 $25,801 - $41,250_____Greater than $41,2502 $0 - $17,700 $17,701 - $29,450 $29,451 - $47,150_____Greater than $47,1503 $0 - $21,720 $21,721 - $33,150 $33,151 - $53,050_____Greater than $53,0504 $0 - $26,200 $26,201 - $36,800 $36,801 - $58,900_____Greater than $58,9005 $0 - $30,680 $30,681 - $39,750 $39,751 - $63,650_____Greater than $63,6506 $0 - $35,160 $35,161 - $42,700 $42,701 - $68,350_____Greater than $68,3507 $0 - $39,640 $39,641 - $45,650 $45,651 - $73,050_____Greater than $73,0508 or more $0 - $44,120 $44,121 - $48,600 $48,601 - $77,750_____Greater than $77,750Source: 2020 HUD low-moderate income level limits for Wood CountyPlease check the box(es) that identify your race. Single Race:Multi-Racial Identifiers: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native and White FORMCHECKBOX Black/African American FORMCHECKBOX Asian and White FORMCHECKBOX Asian FORMCHECKBOX Black/African American and White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX American Indian/Alaskan Native and African/American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other Multi-Racial FORMCHECKBOX OtherPlease answer these questions:Do you consider yourself as being of Hispanic ethnicity? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unemployed or were you unemployed prior to employment with this company? FORMCHECKBOX Yes FORMCHECKBOX NoAre you a female head of household? FORMCHECKBOX Yes FORMCHECKBOX NoI certify that the information provided above is correct to the best of my knowledge_____________________________________ _________________________________ ___/___/_____Printed Name Signature DateEMPLOYER/LOCAL GOVERNMENT USE ONLY (ALL SECTIONS ARE MANDATORY)Position Details? Full Time ? Part Time (FTE: _____) ? Employer-Sponsored Healthcare Plan OfferedPosition Class? Official/Manager ? Professional ? Office/Clerical? Sales ? Technician ? Craft Worker/Skilled? Operative/Semiskilled ? Laborer/Unskilled ? Service WorkerDate Hired: _____/_____/_____Job Category Definitions1. Officials or Managers - Occupants requiring administrative personnel who set broad policies, exercise overall responsibility of execution of these policies, and individual departments or special phases of a firm’s operations. This includes: Officials, Executives, middle management, plant managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers.2. Professional - Occupants requiring either college graduation or experience of such kind and amount as to provide a comparable background includes: accountants and auditors, airplane pilots and navigators, architects, artists chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, professional and labor relations workers, physical scientists, physicians, social scientists, teachers, and kindred workers.3. Technicians - Occupants requiring a combination of basic scientific knowledge and manual skill which can be obtained through about 2 years of post-high school education such as is offered in many technical institutions and junior colleges, or through equivalent on the job training. This includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematic aides, licensed practical or vocational nurses, photographers, radio operators, scientific assistants, surveyors, technical illustrators, technicians (medical, dental, electronic, physical science) and kindred workers.4. Sales - Occupants engaging wholly or primarily in direct selling. This includes: advertising agenda and sales workers; insurance agents and brokers; real estate agents and brokers; sales workers; demonstrators and retail sales workers; and sales clerks, grocery clerks and cashiers; and kindred workers.5. Office or Clerical - Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non-manual though some manual work not directly involved with altering or transporting the products is included. This includes: bookkeepers, cashiers, collectors (bills and accounts), messengers and office helpers, office machine operators, shipping and receiving clerks, stenographers, typists, and secretaries, telegraph and telephone operators, and kindred workers.6. Craft Worker (skilled) - Manual workers of relatively high level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. This includes: the building trades, hourly paid supervisors and lead operators (who are not members of management), mechanic and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers,job setters (metal), motion picture projectionists, pattern and model makers, stationary engineers, tailors, and kindred workers.7. Operatives (semi-skilled) - Workers who operate machines or other equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. This includes: apprentices (auto mechanics, plumbers, electricians, machinists, mechanics, building trades, metal working trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dress makers and sewers (except factory), dryer’s furnaces workers, heaters (metal), laundry and dry cleaning, operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, boiler tenders, truck and tractor drivers, weavers (textile), welders and flame metals workers, and kindred workers.8. Laborers (unskilled) - Workers in manual occupations which generally require no special training perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. This includes: garage laborers; car washers and greasers; gardeners (except farm) and ground keepers; stevedores; wood choppers; laborers performing lifting, digging, mixing loading, and pulling operations; and kindred workers.9. Service Workers - Workers in both protective and non-protective service occupations. This includes attendants (hospital and other institutions, professional and personal service, including nurses aides and orderlies), barbers, chairworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection guards, door keepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, and kindred worker. ................
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