City of Houston Housing and Community Development Public Service Program
Enrollment and Self-Certification of Income
Program: Child Care _______
Juvenile Delinquency Prevention _______
Parent’s Name:___________________________
Date: ____________
Street Address: __________________________________
City / State / Zip: ________________________________________
Home Telephone: ________________________ Work Telephone: ___________________
Female Head of Household Yes_______ No__________
Part I: Household Information
NAME
AGE
GENDER
ETHNICITY
(H/NH
RACE
DISABLED
(Y/N)
CDBG Enrollee
Co-H
Part II: Confidential Participant Beneficiary Income Certification
 Public Assistance Recipient: TANF, SNAP, Foster Care (Documentation Attached)
 Presumed Benefit Recipient : Service designed for severely disabled, homeless, abused
children, persons living with AIDS, (Documentation Attached)
All Other Beneficiaries / Based on: ____ * HUD 24 CFR Part 5 ___ IRS Form 1040
 Family Size _____________
 Total Gross Annual Income* for all adult members is $ ____________
*Documentation must be made available upon request by agency or monitors reviewing the program.
Gross annual income must include all sources of income (wages, child support, SSI, unemployment,
pension, income from assets, but does not include income of live in-aids per 24 CFR 5. 403).
Signature:__________________________
Date:________________
Housing and Community Development Public Service Program SelfCertification (Staff Verification)
Grant #: CCP: ____
JDPP: ____
Name of Public Service (s): ____________________________________________
Name of Agency: ____________________________________________________
Address of Service Provision: ___________________________________________
Program Service Area: Houston, Texas
Effective Date of Income Limit Chart used: April 1, 2021 (Houston-The Woodlands,
Sugarland) Income Limits ($)
Household
Members
1 ___
2 ___
Income
Extremely 16,650
Low
____
Very Low
(50%)
Low
80%
3 ___
4 ___
19,000 21,960
____
____
26,500
____
27,750
_____
31,700 35,650
____
____
39,600
____
44,350
_____
50,700 57,050
____
____
63,350
____
5 __
31,040
____
42,800
____
68,450
____
6 __
7 ___
8 ___
35,580
____
40,120
____
44,650
____
45,950
____
49,150
____
52,300
____
73,500
____
78,600
____
83,650
____
Family is :
 Extremely Low Income (EL)
 Very Low Income (VL)
 Low income (L)
 Over 80% of median income (NLM)
Physical home address is:
 Within Service Area
 Outside of Service Area (Ineligible for Services)
Program Staff:
I certify that the Participant/Beneficiary demographic data and public service information
is true and correct to best of my knowledge for beneficiaries including both, public
assistance or presumed benefit. I certify that using the current Housing and Community
Development annual income publication compared to the stated family size and income,
the income level shown above is true and correct. I certify that Participant/ Beneficiary
residency status is true and correct per the requirements of 24 CFR570.486 (b) and /or (c)
as applicable.
Note: Maintain completed certification in program files for review at the time of
monitoring for all clients (eligible and ineligible)
Signature:__________________________
Date:________________