Employee Self Certification Forms

The Employee Self Certification Form must be completed for all newly hired employees associated with the Community Development Block Grant job creation and job retention programs (PFED, ED, RLF-ED and READI), and can also be used to document section 3 employment.  The Employee Self Certification Form documents the family income and demographics of newly hired employees and should be submitted by the prospective employee to the business with the job application.  An income level in the first three columns of the table indicates a low-to-moderate income (LMI) status.

 Spanish Version

2011 Employee Self Certification Form

2012 Employee Self Certification Form

2013 Employee Self Certification Form

2014 Employee Self Certification Form

2015 Employee Self Certification Form

2016 Employee Self Certification Form

2017 Employee Self Certification Form

2018 Employee Self Certification Form

2019 Employee Self Certification Form​