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Exhibit F <br />HUD CDBG Income Self -Certification & Data Form <br />This organization receives federal funding from the City of Lakewood which requires the collection the following <br />data. We appreciate your cooperation and guarantee the confidentiality of all information provided. <br />Name (please print) <br />I. Household Income <br />Please indicate your annual Household (HH) Income Category based on the information in the table below. A <br />household is defined as all persons living in the same residence related by blood, marriage, or adoption. <br />My Annual Income by Household Size Falls Within (please circle one; Category 1 Category 2 Category 3 <br />Category 4 <br />5 3 5 4 # - X G 4qf rp h.4O 3p 7w<r##F driyhcdgg C -1(� u1d/* K , <br />+hiih:fwlyh* 34 8154*gi&#bcu -,hijjkrwlfh# <br />F duh.j rul f� F dx&lj rul F di&ij rul # F dvhj rul #7 <br />Q rg4Orz C <br />P rg# H {v:hp hcj 0 <br />KK# Igfrp h Orz OP rg# gfrp h Orz.Clgfrp ,h Orz #gfrp, h <br />V 11 h. 3 ( P Ly +8 4 0; 3 ( :' P L -f-6 4 08 3 ( MP L +3 06 3 ( : P 14 <br />4 ' 77/384 . ' S : /$844OW 77/6"9'.,49/i384 5 : /883 ' 3# 49/$ 3 <br />S ' 83iK84. ' 64/784# 83A8j ' ;f/<34" 64./'783 ' 3# 4; /<33 <br />6 ' 89/g84 . ' 68/734$ 89/g83 r4/c94.Fa8X:: <br />33 13 54)k93 <br />7 95/<34 . 6.</834" 9S/<33 ' S9 3 4 C . 3 ' 3" S9/833 <br />8 ' 9 : /<84 . `5J8#I 9 : /<83 ' 644 �75/783 ' 3 64/373 <br />9 : 6/334 ...78J34:.: 6/333 ' 68/$ ; 4 78�33 ' 3$ 68/8 ; 3 <br />/334 . ' 73,�54 7,, :'$3 ' 3# 73/453 <br />6/384 . ' 77/ )94 84`;A 3. ' 3# 77493 <br />II. Race/Ethnici <br />- n�r ericall Ii ` ar /Alask' dative & its <br />A sian &White <br />1 <br />Ilack/African Amrin & V'Jte <br />American Indian/Alaskan & B lZafrican <br />Othef multi -Racial <br />III. Female Head of Household <br />IV. Senior Citizen 62+ ears . , <br />V. Currently Have Health c <br />VI. Currently Unemployed <br />❑ Yes ❑ No <br />ge ❑ Yes ❑ No <br />enefits ❑ Yes ❑ No <br />❑ Yes ❑ No <br />I hereby attest the information provided is true and accurate to the best of my knowledge. <br />Signature <br />La is <br />