Owner Household Income Information: Estimate the annual income of the household by projecting the total gross amount of income for all persons (related or not) living in the household at the time the assistance was requested. Estimated annual income shall include income from all sources of household members including social security and retirement. Income derived from the CDBG-assisted job shall not be considered in calculating estimated annual income.
The applicant is a Veteran under the following criteria: "Any former member of the armed forces who was discharged or released from duty under any conditions other than dishonorable, as well as active and former members of the Reserve, National Guard, and active duty military members preparing to transition to civilian life."
I request business management counseling service from a Small Business Administration Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I further
agree to be included in this SBA partner’s email distribution list and that upon receipt of email communications I will be given the opportunity to unsubscribe. I authorize SBA to furnish relevant information to the assigned management counselor(s). I understand that any information disclosed to be held in strict confidence by him/her. I further understand that any counselor has agreed not to: (1) recommend goods or services from sources in which he/she has an interest and (2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management of technical assistance, I waive all claims against SBA personnel, BiGAUSTIN and its host organizations, and other SBA Resource Counselors arising from this assistance. Please note: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0091) PLEASE DO NOT SEND FORMS TO OMB.
City of Austin Owner Disclaimer *
Evidenced by checking below, Owner certifies his or her annual household income. Owner certifies that the information herein provided is true and accurate. Owner further acknowledges that any inaccuracy and/or misrepresentation provided herein may constitute fraud, which is punishable by law. Owner certifies that all information herein and any attachments hereto, are true and correct as of the date set forth opposite signature. Owner acknowledges that Title 18, Section 1001 of the US Code states that any person that makes intentional or negligent statements to any department of the United States Government is guilty of a felony that could result in but not be limited to a fine, imprisonment, or both.
This activity is funded with federal Community Development Block Grant (CDBG) funds and is designed to primarily benefit low to moderate-income households (LMI) through the provision of assistance to micro-enterprises under 24 CFR 570.201(o). A micro-enterprise is a business that has no more than 5 employees, of which, one is the owner. The microenterprise business owner must also be an income eligible household in order to meet the federal micro-enterprise definition and participate in the program. Owner should not provide his/her signature unless he/she has read and understands the income information they are certifying under penalty of law. At the discretion of the program, Owner may be required to provide documentation to the Program to confirm the self-declaration of income.