RACIAL DESIGNATION. (select one or more) for each household, enter the number of family members by each applicable race. □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Other Pacific Islander □ American Indian/Alaskan Native & White □ Asian & White □ Black/African American & White □ American Indian/Alaskan Native & Black/African American □ Other CERTIFICATION: "To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." Print Name Date Sign Name If you need assistance completing this form, please check with the Sub-Recipient Agreement for assistance. For Grantee Use Only Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Extremely Low (b) Very Low (c) Low (d) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS Non-LMI TOTAL Non-LMI PERSONS
RACIAL DESIGNATION. Indicate number of family members in each individual category below: White Black/ African American Asian American Indian/ Native Hawaiian/ Other American Indian/ Alaskan Alaskan Native Pacific Islander Native & White Asian & White Black/African American American Indian/ Alaskan & White Native & Black/ African Other American CERTIFICATION: “To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD” Print Name Date Sign Name If you need assistance completing this form, please check with the Community Clinic of Joplin for assistance. For Sub-Recipient Use Only Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Extremely Low (b) Low (c) Moderate (d) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS Non-LMI Families (e) TOTAL Non-LMI PERSONS
RACIAL DESIGNATION. ( select one or more) for each household, enter the number by race.
RACIAL DESIGNATION. (select one or more) for each household, enter the number by race. ☐ White ☐ Black/African American ☐ Asian ☐ American Indian/Alaskan Native ☐ Native Hawaiian/Other Pacific Islander ☐ American Indian/Alaskan Native & White ☐ Asian & White ☐ Black/African American & White. ☐ American Indian/Alaskan Native & Black/African American. ☐ Other Multi-Racial.
