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This document is a IN PROGRESS Form.
Baltimore Co. CDBG Self Cert Form & Language Survey/HUD Racial Def. (2 pgs., Rev. 2023)
EXHIBIT D: SELF- CERTIFICATION FORM (**SAMPLE**) 2 PAGES
BALTIMORE COUNTY
COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM (CDBG)
SELF-CERTIFICATION FORM
Information on annual household income, race and ethnicity is required to determine participant eligibility for services funded by Baltimore County through
the Community Development Block Grant (CDBG) Program. Each participant is required to provide information regarding the number of persons in their
family and the household’s annual income. Information provided is subject to verification by Baltimore County and the U.S. Department of Housing and
Urban Development (HUD).
NOTE: “Income” is the total annual income of all family members as of the date of application. All income for all persons in the family must be included
in calculating family income whether or not a family member receives assistance. Additional expected sources of income and the amount expected during
the period of assistance must be included in the calculation of annual family income.
INSTRUCTIONS:
1) Circle the number of persons in your household (adults and children).
2) Stay in that same column for your household size and look down the column at the three household income limits.
3) Circle the income limit that is closest to your household income, but is NOT LESS THAN your household income. Remember household income
includes the monies earned and/or benefits received by all household members.
4) Check the appropriate Ethnicity and Race
5) Sign and date the bottom to certify your household size and household income.
FY 2025 Income Limit
Area
Median Family
Income
FY 2025 Income
Limit Category
Persons in Family
1
2
4
5
6
7
8
Baltimore-Columbia-
Towson, MD MSA
$130,300
Very Low (50%)
Income Limits ($)
45,650
52,150
65,150
70,400
75,600
80,800
86,000
Extremely Low
Income Limits ($)
27,400
31,300
39,100
42,250
45,400
48,650
54,150
Low (80%) Income
Limits ($)
72,950
83,400
104,200
112,550
120,900
129,250
137,550
Is this a Female Headed Household? (Pick 1 of 2): ❑ Yes or ❑ No
Please check Ethnicity (Pick 1 of 2): ❑ Hispanic or ❑ Non-Hispanic
Please check Race* (Pick 1 of 10 choices):
*Refer to HUD’s Racial Definitions on the bottom half of the reverse side of this form for additional information.
❑ White ❑ American Indian/Alaskan Native and White
❑ Black or African-American ❑ Asian and White
❑ Asian ❑ Black/African-American and White
❑ American Indian or Alaskan Native ❑ American Indian/Alaskan Native and Black/African-American
❑ Native Hawaiian or Other Pacific Islander ❑ Other-Multi-Racial (ONLY select if no other category as defined on
the back of this form, applies.)
APPLICANT STATEMENT: I certify that the information given on this form is true and accurate to the best of my knowledge. I am aware that there are penalties for willfully
and knowingly giving false information on an applicant for Federal, State or County funds, which may include immediate repayment of all Federal, State or County funds received
and /or prosecution under the law. I understand that the information on this form is subject to verification by County, State or Federal personnel as part of compliance monitoring.
I agree to provide, upon request, documentation on all income sources.
Applicant Name (Please Print):
Address (Street & City):
Zip: County:
Applicant Signature: Date:
**PLEASE COMPLETE LANGUAGE SURVEY ON REVERSE SIDE**