SELECT ONLY ONE OF THE FIVE CATEGORIES BELOW FOR EACH BOARD MEMBER (Appropriate Documentation Must Be Provided) Name of CHDO ____________________________ Note, if a board member is a public official, appointee, or governmental employee, Board of Directors that member cannot be counted as a LI representative. Resident of a Elected Low-Income Public Employer (If Term Representative of Low-Income Current Board County of Private Official, Household unemployed, indicate Expiration a Low-Income Neighborhood Member Name Residence Appointee, Sector reason such as student, (below 80% Neighborhood Date (must provide US retired, disabled, etc.) or Employee AMI) Organization Census data) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I certify that this listing of current, participating board members is accurate. ________________________________________ _________________________ Board President Signature Date
Name of CHDO ____________________________ Board of Directors SELECT ONLY ONE OF THE FIVE CATEGORIES BELOW FOR EACH BOARD MEMBER (Appropriate Documentation Must Be Provided) Note, if a board member is a public official, appointee, or governmental employee, that member cannot be counted as a LI representative. Current Board Member Name County of Residence Employer (If unemployed, indicate reason such as student, retired, disabled, etc.) Low-Income Household (below 80% AMI) Resident of a Low-Income Neighborhood (must provide US Census data) Elected Representative of a Low-Income Neighborhood Organization Public Official, Appointee, or Employee Private Sector Term Expiration Date 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I certify that this listing of current, participating board members is accurate. ________________________________________ _________________________ Board President Signature Date
2016_chdo_application.docx