Head of Household: Household Size: CSBG 125% FY2017 FEDERAL POVERTY INCOME GUIDELINES For each additional household member add: Household Size Annual Gross Income $5225.00 1 $15,075 Income Information 2 $20,300 Earned and Unearned Income: Starting with applicant, list all 3 $25,525 household members who received Earned and/or Unearned Income. 4 $30,750 5 $35,975 6 $41,200 GROSS Past Name (Last/First) 7 $46,425 30 Days Total Annual 8 $51,650 Source Annual Income $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL Annual Income (Last Column) Income Source 1. SS (Social Security) 2. Wages 3. SSI/SSDA/SSA/Social Security 4. GA 5. ADC/TANF/CASH 6. Pension/Retirement 7. Self-Employment 8. Unemployment 9. Child Support 10. Other _________________________________________________ [ ] APPROVED Vendor/Company/Recipient: Amount: $ Justification: Account #: Vendor/Company/Recipient: Amount: $ Justification: Account #: [ ] DENIED Reason: ______ ______________ Approved by: CAP Administrator Date If you disagree with this decision, you have a right to an appeal. Hearing process sheets can be obtained in the CAP office.
Head of Household: Household Size: CSBG 125% FY2017 FEDERAL POVERTY INCOME GUIDELINES Household Size Annual Gross Income 1 $15,075 2 $20,300 3 $25,525 4 $30,750 5 $35,975 6 $41,200 7 $46,425 8 $51,650 For each additional household member add: $5225.00 Income Information Earned and Unearned Income: Starting with applicant, list all household members who received Earned and/or Unearned Income. Name (Last/First) Source Annual Income GROSS Past 30 Days Total Annual $ $ $ $ $ $ $ $ $ $ $ $ TOTAL Annual Income (Last Column) $ Income Source 1. SS (Social Security) 2. Wages 3. SSI/SSDA/SSA/Social Security 4. GA 5. ADC/TANF/CASH 6. Pension/Retirement 7. Self-Employment 8. Unemployment 9. Child Support 10. Other _________________________________________________ [ ] APPROVED Vendor/Company/Recipient: Amount: $ Justification: Account #: Vendor/Company/Recipient: Amount: $ Justification: Account #: [ ] DENIED Reason: ______ ______________ Approved by: CAP Administrator Date If you disagree with this decision, you have a right to an appeal. Hearing process sheets can be obtained in the CAP office.
CSGB%20APPLICATION%20FY%202018%20color%20final.docx