Attachment B:
Meeting LMJ National Objective
All CDBG-funded activities must meet a CDBG program national objective. The national objective for this program is to retain jobs and/or benefit areas with low-and moderate- income (LMI) persons. To be eligible for this grant, the business must meet the Low Mod Job Creation & Retention (LMJ) criteria. The business meets the national objective if it creates or retains permanent jobs, at least 51 percent of which (computed on a full-time equivalent basis) will be made available to or held by LMI persons, the identified LMI staff reside in an eligible census tract with at least 70 percent LMI persons, OR the business is in an eligible census tract (refer to Eligibility Checklist for details) and the job will be located within that same census tract.
Please complete all the information below for the business.
BUSINESS INFORMATION
Business owner name(s):
Business name: _
Total number of current employees: Full-Time: _______ Part-Time: _______ Describe the financial impact that the business is facing that requires grant assistance. The answer should demonstrate how the grant funds will assist the business in creating new job(s) or retaining their staff.
I hereby certify under penalty of perjury that the above information I have provided in this application is true & correct. I acknowledge and understand that the information provided here will be relied upon for purposes of determining my eligibility for this program. I acknowledge that a material misstatement fraudulently or negligently made in this or in any other statement made by me may constitute a federal violation and may result in the denial of my participation in this program.
Signature of Participant
Date
SECTION A.1-COMPLETE ONLY IF GRANT FUNDS WILL BE USED TO RETAIN STAFF
INCOME CERTIFICATION
Per HUD requirements the business must demonstrate 51 percent of jobs (computed on a full-time equivalent basis) are retained and/or created and will be made available to or held by LMI persons or that LMI staff reside in an eligible census tract with at least 70 percent LMI persons. The business is required to have all employed staff complete the Participant Data Form on Pages (4-5) to demonstrate that it meets the LMI requirement. You will need the information collected from these forms to complete the Employee Table below.
EMPLOYEE TABLE
Using the information gathered from the CDBG Participant Data Form complete the table below for all staff the business employs. Attach additional sheets if needed.
Employee Name
Job Title
Hourly Wage
Average Hours Worked Weekly
Frequency of Pay
Household Size
1 2
3 4
5 6
7 8
9 10
11 12
13 14
15 ☐ I have attached payroll records/registers as documentation to support the information provided above.
SECTION A.2-COMPLETE ONLY IF GRANT FUNDS WILL BE USED TO CREATE JOBS If the business intends to use grant funds to create jobs, please submit the listed documents. If documents are not currently available, the business will need to work with program staff to provide them as they become available.
Documents to Submit
Job Description
Applicant Resume(s)
Job postings (social media, career websites etc.)
Proof that the business made efforts to make the job available to low-and moderate- income (LMI) persons.
Once the position has been filled:
Resume
CDBG Participant Form (if filled by LMI person)
Payroll Register/Report & Timecards
THIS SECTION TO BE COMPLETED BY PROGRAM STAFF ONLY.
Employee Name
Full/Part Time
Frequency of Pay
Average Weekly Hours
Annual Income
LMI?
Income Level
Staff Signature Date
City of Rialto
CDBG Participant Data Form
The business is required to have all employed staff complete the Participant Data Form
PARTICIPANT INFORMATION
Name
Address
Phone Number
☐Home ☐Cell
Job Description
Title:
☐Full-time ☐Part-time
PARTICIPANT AND HOUSEHOLD BACKGROUND
Gender
☐ Male
☐ Female
Age
☐ 18-24
☐ 25-61
☐ 62+
Household Size
number of persons living in the same house
☐ 1
☐ 2
☐ 3
☐ 4
☐ ______
Total Household Income
see chart below
☐ Extremely Low
☐ Very Low
☐ Low
☐ Other
Is the head of your household female?
☐ Yes
☐ No
Total Household Income Chart
1. Find your Household Size.
2. In that row, circle the range where your Total Household Income lies.
ADDITIONAL ELIGIBILITY INFORMATION
Are you disabled?
☐ Yes
☐ No
Are you currently homeless?
☐ Yes
☐ No
Are you a senior?
☐ Yes
☐ No
Do you receive income from any of these sources?
☐ CalWorks
☐ Social Security
☐ CalFresh
☐ General Assistance
☐ MediCal
☐ Other:
RACE AND ETHNICITY
Race
check one
Hispanic Ethnicity
check if yes
☐
White
☐
☐
Black/African American
☐
☐
Asian
☐
☐
American Indian/Alaskan Native
☐
☐
Black/African American & White
☐
☐
Asian & White
☐
☐
American Indian/Alaskan Native & White
☐
☐
American Indian/Alaskan Native & Black/African American ☐
☐
Other Multi-Racial
☐
☐
Decline to State
Acknowledgment and Disclaimer
The abovementioned program is funded, in part, by the U.S. Department of Housing and Urban Development (HUD). HUD monitors the City as to the income and ethnicity of program participants. The information being requested is only for monitoring and auditing purposes, as required by HUD. It is not intended for public dissemination.
This application must be completed and signed by the participant or the participant's legal guardian who seeks to receive benefits from the program listed above. Proof of residence and household income may be requested.
I hereby certify under penalty of perjury that the above information I have provided in this application is true & correct. I acknowledge and understand that the information provided here will be relied upon for purposes of determining my eligibility for this program. I acknowledge that a material misstatement fraudulently or negligently made in this or in any other statement made by me may constitute a federal violation and may result in the denial of my participation in this program.
Signature of Participant
Date
DISCLAIMER: The submittal of information herein does not guarantee any award of funding from the City of Rialto or constitute a financial commitment thereof. Grant funds are subject to applicable federal and local funding limitations and the City of Rialto’s verification of various eligibility requirements. 2/5
DISCLAIMER: The submittal of information herein does not guarantee any award of funding from the City of El Monte or constitute a financial commitment thereof. Grant funds are subject to applicable federal and local funding limitations and the City of El Monte’s verification of various eligibility requirements.