Household Information Household Size* Heads of Households* Female Indicate all names of individuals in this category
Male Indicate all names of individuals in this category
Other Indicate all names of individuals in this category
Number of Adults in Household* Number of Children in Household* Ethnicity of Household Members Hispanic* Non-Hispanic* Race of Household Members White European or Caucasian* Native Hawaiian* Pacific Islander* Micronesian* Samoan* Other Pacific Islander* Other
Asian or Asian-American* Black or African-American* Latino, or Latin American* Puerto Rican* American Indian or Alaskan Native* Other Ethnicity of Family Other
Mixed Race* Asian & White* American Indian/Alaskan Native & White* American Indian/Alaksan Native & Black* Black/African American & White* Other Multi-Racial* Other
Seniors Seniors (Age 62+)* Names* Indicate all names of individuals in this category
Health Concerns for the household Diabetes Heart disease Household members with disabilities Mentally Disabled* Names Indicate all names of individuals in this category
Physically Disabled* Names Indicate all names of individuals in this category
Other* Names Indicate all names of individuals in this category
Employment Employed* Unemployed, not in school* Household Veterans Yes* No* Students & Children Full-Time Students in Family* Full-time student age 18+ Names Indicate all names of children in this category
Child under the age of 18* Names Indicate all names of children in this category
Minor under age 15* Names Indicate all names of children in this category
Child under age 5* Names Indicate all names of children in this category
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Family Income (Total Annual Family Income) This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Please review if your household income is at or below these numbers, which will allow you to participate in additional programs: 2020 ANNUAL HOUSEHOLD INCOME GUIDELINES (185% of poverty)
Family Size
Income
1
$27,158.00
2
$36,686.00
3
$46,213.00
4
$55,740.00
5
$65,268.00
6
$74,796.00
7
$84,323.00
8
$93,851.00
I certify that my yearly gross income is at or below that income listed on this form for households with the same number of people as my household, OR that my household participates in the TEFAP program. I also certify that, as of today, my household lives in the County of Honolulu. This certification form is being completed in connection with the receipt of Federal assistance. Per State policy, program officials may verify what I have certified to be true. I understand that making a false statement may result in having to pay the State for the value of the food improperly issued to me and may subject me to criminal prosecution under State and Federal law. Yes, I certify No, I am not eligible
AGREEMENT* WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.
