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Small Business Assistance Income Verification Form

  1. Introduction

    We are asking your cooperation in completing this form for record keeping purposes to verify both the job retention and income benefits being provided through the City of Modesto’s Small Business Assistance Program. Please be assured that this information will remain confidential and will be used only to meet the record keeping requirements of the U.S. Department of Housing and Urban Development, which is providing the CDBG-CV funds to help retain your job.

  2. Title II Compliance
    In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.
  3. Are you the Business Owner or an Employee?*
  4. Is your position Full Time or Part Time?*
  5. Is this a new or existing job for you?*
  6. Round up to the nearest dollar.
  7. Head of Household*
    (Check all that apply)
  8. Ethnicity*
  9. Race*
  10. Acceptance*
    Review and check the following.
  11. Electronic Signature Agreement*
    By Checking "I Accept", you agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
  12. By signing this form electronically, 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.
  13. Leave This Blank:

  14. This field is not part of the form submission.