HomeMy WebLinkAboutPresumed Clientele Form COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM YEAR 2015 - 2016
SELF-CERTIFICATION FOR PRESUMED CLIENTELE
1) CLIENTE INFORMATION:
Name:
(Please Print)
Address or Mailing Address:
City&State: Zip
2) CATEGORY: I certify that [I am/my family is/arel eligible under 24 CFR 570.208(a)(2)(i)(A) guidelines:
(A) Senior Citizen (E) Homeless Person
(B) Severely Disabled Adult* (F) Illiterate Adults*
(C) Abused Child* (G) Victim of Domestic Violence
(D) Migrant Farm Worker (H) Person Living with AIDS
* If this certification is being filled out on behalf of a qualifying individual, please indicate so in the
certification box below.
3) FAMILY SIZE (check ONLY one): 1❑ 2❑ 3❑ 4❑ 5❑ 6❑ 7❑ 8❑
4) ETHNICITY(Select ONLY one from the Single-race or Multi-race categories):
Single race category
❑ White 0 American Indian/Alaskan Native
❑ Black/African American 0 Native Hawaiian/Other Pacific Islander
❑ Asian
Multi-race category
❑ American Indian/Alaskan Native&White 0 Asian& White
O Black/African American&White 0 Hispanic/White
❑ Hispanic/Black/African American 0 Hispanic/Asian
O Hispanic/American Indian/Alaskan Native 0 Hispanic/Asian& White
❑ Hispanic/Native Hawaiian/Other Pacific Islander 0 Hispanic/Black/African American&White
❑ Hispanic/American Indian/Alaskan Native&White
❑ American Indian/Alaskan Native&Black/African American
❑ Hispanic/American Indian/Alaskan Native&Black/African American
O Other Multi-race(ONLY if,non-of-the-above categories identifies you).
5) CERTIFICATION:
I, (Signature), on (Date).
hereby acknowledge that eligibility for assistance under this CDBG-funded program is based upon my
qualification as a person/family meeting the "presumed" category under 24 CFR Part 5 70.208(a) (2) (i) (A). I
agree to provide supporting documentation if requested by the County of Riverside or the U.S. Department of
Housing and Urban Development(HUD).
I have completed this certification on behalf of the client named in Section 1 above
(Signature) (Date)
PROGRAMA DE BECA DE DESARROLLO A LA COMUNIDAD (CDBG)
AUTO-CERTIFICACION DE ELIGIBILIDAD
(No para use a albergar las actividades)
1) INFORMACION DEL CLIENTE:
Ano del Proyecto:
Nombre:
Dirección o Dirección Postal:
Ciudad y Estado: Codigo Postal
2) CATEGORIA: Certifico que [soy/mi familia es/son] elegible bajo las pautas 24 CFR 570.208(a)(2)(i)(A).
(A) Persona de la tercera edad (D) Jornalero Migratorio (G) Violencia domestica
(B) Severamente Incapacitado (E) sin hogar (H) SIDA
(C) Ninos abusados (F) Adultos analfabetos
3) NUMERO DE FAMILIA (marque solamente uno):1 0 20 30 40 5 6 70 8
4) GRUPO ETNICO: (Solamente seleccione una de las categorias de razas/multi-razas la cual lo describe a
usted).
Categoria de raza individual
❑ White 0 American India/Alaskan Nativa
❑ Black/Africano American 0 Nativa Hawaiana/Otro Pacifica Islandes
❑ Asian
Categoria de Multi-raza
❑ American India/Alaskan Nativa&White 0 Asian&White
O Black/Africano American&White 0 Hispanico/White
❑ HispanicoBlack/Africano American 0 Hispanico/Asian
O Hispanico/American India/Alaskan Nativa 0 Hispanico/Asian&White
O Hispanico/Nativa hawaiano/Otro Pacifica Islandes ❑ HispanicoBlack/Africano American&White
❑ Hispanico/American India/Alaskan Nativa&White
❑ American India/Alaskan Nativa&Black/Africano American
❑ Hispanico/American India/Alaskan Nativa&Black/Africano American
O Otro(solamente seleccione si ninguna de las categorias mencionadas se identifican con su etnicidad).
Yo, (firma), en (Fecha),por la presente
reconozco que los requisitos para la ayuda financiera bajo el programa de CDBG es basado sobre mi calificacion como
persona/familia cumpliendo respectivamente bajo la"supuesta" categoria 24 CFR 570.208(a)(2)(i)(A). Yo estoy de
acuerdo en proveer documentacion valida,si es que fuera requerido por el Condado de Riverside o el Departamento de
Vivienda y Desarrollo Urbano de los Estados Unidos(HUD).
CDBG Desk Guide Glossary
Presumed means as the term is defined in 24 CFR 570.208(a)(2)(i)(A):
Benefit a clientele who are generally presumed to be principally low and moderate income persons.
Activities that exclusively serve a group of persons in any one or a combination of the following
categories may be presumed to benefit persons, 51 percent of whom are low-and moderate-income:
(A) abused children,
(B) battered spouses,
(C) elderly persons,
(D) adults meeting the Bureau of the Census' Current Population Reports definition of " "severely
disabled,"
(E) homeless persons,
(F) illiterate adults,
(G) persons living with AIDS, and
(H) migrant farm workers
Homeless means as the term is defined in 42 U.S.C. 11302, in general - for purposes of this Act, the
term "homeless" or"homeless individual or homeless person" includes:
(1) an individual who lacks a fixed, regular, and adequate nighttime residence; and
(2) an individual who has a primary nighttime residence that is:
A) supervised publicly or privately operated shelter designed to provide temporary living
accommodations (including welfare hotels, congregate shelters, and transitional housing for the
mentally ill);
B) a institution that provides a temporary residence for individuals intended to be institutionalized;
or
C) a public or private place not designed for, or ordinarily used as, a regular sleeping
accommodations for human beings.