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NOTICE TO EMPLOYEE <br /> The development of this project and the creation of these jobs are-being assisted <br /> •with Community Development Block Grant (CDBG) funds provided to us from , <br /> (City/County) <br /> which it receives from the MN Department of Trade and Economic Development. A <br /> requirement of this assistance is that we collect data on employees. Therefore, we ask <br /> that you answer the questions below. This information will not be disclosed or released <br /> by this office without your consent, except to the and to the <br /> (City/County <br /> Department of Trade and Economic Development (DTED) . <br /> Are you . . . Male Female Female Head of Household Handicapped <br /> Are you White (not Hispanic) <br /> Black (not Hispanic) <br /> American Indian or Alaskan Native <br /> Hispanic <br /> Asian or Pacific Islander <br /> A. TAKEN BY: <br /> What is the number of adults and children living in your household including <br /> yourself? <br /> For the past year what was the total family income (before taxes). for all members of <br /> your household? Please check the appropriate response across from the family <br /> size you listed above. <br /> LOW-INCOME LMI NON-LMI <br /> 1 .member: $ or less, $ - _ S. or more <br /> 412 members: $ or less, $ - $ or more <br /> 3 members: $ or less, $ - $ or more <br /> 4 members: — $ or less, $ - $ or more <br /> 5 members: — $ or less, $ - $ or more <br /> 6 members: — $ or less, $ - $ or more <br /> 7 members: — $ or less, $ - $ or more <br /> 8 members: — $ or less, $ - $ or more <br /> If requested, I would agree to make my financial records available to the <br /> or DIED for verification of the above information. <br /> (City/Co) . <br /> I certify that the information above is, to the best of my knowledge and belief, a <br /> true, correct and complete statement of my financial condition as of the date stated <br /> herein. <br /> Signature Date <br /> Warning: Section 1001 of Title 18 of the United States Code (Criminal Code and <br /> Criminal Procedure) shall apply to the foregoing certification, Title 18 provides, <br /> among other things, that whoever, knowingly and willingly makes or uses a document or <br /> writing containing any false, fictitious or fraudulent statement or entry, in any manner <br /> within the jurisdiction of any department or agency of the United States, shall be fined <br /> more than $10,000 or imprisoned not more than five years, or both. <br /> Prospective Employee Stop Here <br />