Santa Ana, CA · Orange County
CDBG Program Statistical Information and Income Self-Certification Form
Santa Ana CDBG participants use this form to report household demographics and income and certify information for federal program reporting.
What this form is
Federally funded Community Development Block Grant participants must disclose statistical and family income information to participate. The form collects applicant and household-member details, household size, income sources, and annual gross income, with an income calculation worksheet. It also lists supporting income documents to submit for each household member age 18 or older and includes a certification signed by the applicant.
Who needs it
Santa Ana residents participating in the CDBG program complete the form and provide income information and documentation for household members age 18 or older.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the applicant certifies the information under penalty of perjury and signs and dates the form.
How to submit this form
- 1
Download The Form
Download the CDBG statistical information and income self-certification PDF.
- 2
Complete The Form
Enter applicant and household details, identify income sources, and calculate total annual family gross income.
- 3
Gather Income Documents
Provide the listed supporting income documentation for each family member age 18 or older.
- 4
Sign And Submit
Read the certification, sign and date the form, and submit it to the city department named on the form.
Frequently asked questions
- What is the CDBG Program Statistical Information and Income Self-Certification Form?
- It collects demographic and household income information from CDBG participants for federal reporting, along with income documentation and an income calculation worksheet.
- Who completes the Santa Ana CDBG income form?
- Federally funded CDBG participants complete it. The form requests information about household members and income documentation for each family member age 18 or older.
- Do I need a notary for the Santa Ana CDBG income form?
- No. The document is signed without a notary; the applicant certifies the information under penalty of perjury and signs and dates the form.
- How do I submit the Santa Ana CDBG income form?
- Submit it to the city department named on the form; check the city website for current contact details.