Volunteer Legal Services Hawaii

Self-Certification of Family Size and Income

The COVID Legal Prevention Project was made possible with federal Community Development Block Grant (CDBG) funds provided by the U.S. Department of Housing and Urban Development (HUD) through the City & County of Honolulu (City). The CDBG program requires information on family size and income so that it is evident that a portion of Volunteer Legal Services Hawaii clients are from low and moderate-income households. Your cooperation in completing this form is appreciated.

NOTE: "Income" is the total annual income of all family members living in the same household as of the date of admissions. Income includes wages, interest, and dividends, child support, SSI, unemployment, pension, etc. It does not include food stamps or Section 8.

Check box which represents family size and income level (required):

HUD Program Income Limits, Honolulu, Hawaii MSA, FY 2015, effective March, 6, 2015
Family Size Total Annual Family Income Total Annual Family Income Total Annual Family Income Total Annual Family Income

Applicant Statement. "I certify that the information given on this form is true and accurate to the best of my knowledge. I am aware that there are penalties for willfully and knowingly giving false information on an application for Federal or State funds. Penalties for falsifying information may include immediate repayment of all Federal or State funds received and/or prosecution under the law. I understand that the information on this form is subject to verificiation."

Email address to receive copy of digitally signed pdf

If you prefer, download the Self-Certification of Family Size and Income Form to complete and return by mail.