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2. CITY OF NASHUA
   COMMUNITY DEVELOPMENT DIVISION
4. SELF - DECLARATION OF INCOME
   COVID-19 IMPACT FUND
6. REPORTING INSTRUCTIONS
   Federal regulations require we obtain this information to document assistance is being provided to low and moderate-income households. When completing this form please include all persons residing within your household, regardless of whether or not they are related. Information provided on this form is kept confidential, and shared only with local, state or federal auditors to confirm program compliance.
8. DATE*
   DATE
10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip Code
19. Phone Number
20. Email Address
22. Business Name
24. ETHNICITY (please select only one):*

    1. Hispanic or Latino

    1. Not Hispanic or Latino
26. RACE (please select only one):

    1. White
    2. Black/African American
    3. Asian
    4. American Indian/Alaska Native American
    5. Native Hawaiian/Other Pacific Islander

    1. American Indian/Alaskan Native and White
    2. Asian and White
    3. Black/African American and White
    4. American Indian/Alaskan Native and Black/African
    5. Other Multi-Racial
28. 
30. A household that is over 80% is not eligible to receive funding.

    Please note, the links in the chart above are not active.  You can view "More Detail" on HUD's website.  The chart above is for reference only. 

32. Family Size*
33. Annual Gross Income*
35. Check here if unemployed

    1. Unemployed
36. If not working provide a brief description of how you cover expenses.
38. I certify the above information is true and correct to the best of my knowledge.
40. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
42. Electronic Signature
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field