DIRECT BENEFITS/STATUS FORM (CDA 35) INSTRUCTIONS



YEAR 2019

CLIENT INCOME CERTIFICATION OF FAMILY SIZE AND INCOME

(For CDBG Federally-Funded Programs in Waukesha County)

AGENCY NAME: ____________________________Funded Program: ______________________

The following information is needed because we are a government-funded agency and they require that we verify the income of the clients that we serve.

MY CURRENT FAMILY SIZE AND INCOME LEVEL IS CIRCLED BELOW: (Circle the appropriate number in your family and income level). Reportable income includes wages, salaries, pensions, child support, rental income, investment income.

CERTIFICATION OF FAMILY SIZE AND INCOME

Family Income (at time of entry into your CDBG program) - Circle number of related individuals living in your home, and Family Income

(HUD Income Limits)

NUMBER IN EXTREMELY LOW LOW MODERATE INCOME NON LOW MODERATE

HOUSEHOLD INCOME LEVEL INCOME LEVEL LEVEL INCOME LEVEL

1 $ 17,300 $ 17,301- $28,850 $ 28,851 - $46,100 Over $46,100

2 19,800 19,801 - 32,950 32,951 - 52,700 Over $52,700

3 22,250 22,251 - 37,050 37,051 - 59,300 Over $59,300

4 25,750 25,751 - 41,150 41,151 - 65,850 Over $65,850

5 30,170 30,171 - 44,450 44,451 - 71,150 Over $71,150

6 34,590 34,591 - 47,750 47,751 - 76,400 Over $76,400

7 39,010 39,011 - 51,050 51,051 - 81,700 Over $81,700

8 43,430 43,431 - 54,350 54,351 - 86,950 Over $86,950

Please note: move straight across chart after circling number in household

DEFINITIONS:

1) Extremely Low Income Level. This income level is at or less than 30% of County Median Income.

2) Low Income Level. This income level is between 31% and 50% of County Median Income.

3) Moderate Income Level. This income level is between 51% and 80% of County Median Income.

4) Non Low Moderate Income – Above 80% of County Median Income.

Client Name:_____________________________________

(Please Print)

Client Signature:____________________________________ Date: ____________________

Address: _____________________________City:_______________ Zip Code: ___________

Signature of Agency Representative: _____________________________Date:___________

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