10-29-1984 Council Packet - Laserfiche WebLink

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UHC/1183 URBAN HENNEPIN COUNTY UTILITIES CONNECTION GRANT PROGRAM HOMEOWNER APPLICATION FOR. GRANT HOUSEHOLD INFORMATION -- Please Print First Name Name of Spouse Address Home Phone City Zip Code Work Phone City of residence if other than mailing address Marital Status (check one) married, single, divorced, separated, widowed Race (check one) White, Black, American Indian/Native Alaskan, Hispanic, Asian or Pacific Islander The information concerning Minority Group Categories is requested for statistical purposes only so that Hennepin County may determine the degree to which its programs are utilized by Minority households. INCOME INFORMATION "income" means any amount received from the following sources by a Resident. * Any public assistance * Salaries, including commissions, tips, * VA educational grants bonuses, and overtime pay * Estate or trust income * Rental income * Gains from the sale of * Business profit for self-employed, property or securities including farmers and child care, etc. * Pensions and annuities, * Payments received from property being including social security sold on contract for deed and PERA * All other income received by the * Alimony and/or child support household * Interest and dividends List all the residents of your household. Include yourself. Include their ages and their incomes, if any. "RESIDENT" means any person, other than a renter, living in the household for at least nine (9) months of the year, or a person who is claimed as a dependent for income tax purposes. Total number of residents in the household OFFICE USE ONLY names of residents income of ages of residents residents Per month S S S S S S S -otal :ncome - )er montn source of income in household verified incomes 3 S S S S S S S ncome oer nonth S Income perr _Fnr—