FORM 998-B2
Declaration of Household Income
City of Manteca Utility Billing
THIS SECTION TO BE COMPLETED BY ACCOUNT HOLDER
Household Income Guidelines
Effective April 18, 2022
Number of
People in
Household
1 2 3 4 5 6 7 8 Each
additional
person
Maximum
Gross
Household
Income
$29,000 $33,150 $37,300 $41,400 $44,750 $48,050 $51,350 $54,650 $3,300
LIST OF HOUSEHOLD INCOME
List all household members currently residing at the service address, regardless of their earning status. Unearned income may include any monies from spouse/partner, SSI/SSD, welfare benefits, unemployment, student grants, rental income, interest, dividends, cash, and/or gifts
Current Household Members
(Last Name, First Name)
Relationship Age Employed?
(Yes/No)
Employment
Income (Monthly)
Unearned
Income
(Monthly)
1. Head of Household
2. 3.
4. 5.
6. 7.
8. Employment and Unearned Income Totals:
DECLARATION OF HOUSEHOLD INCOME (All household members 18 years of age or older must sign this declaration) I, the undersigned, declare under penalty of perjury under the laws of the State of California that the above information is true and correct.
Print Name Signature Relationship
1. Head of Household
2. 3.
4. 5.
6. 7.
8. THIS SECTION TO BE COMPLETED BY CITY STAFF
Date & Time Received Received By Completed By
ATTACHMENT 5