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<br />. <br /> <br />. <br /> <br />. <br /> <br />NOTICE TO PROSPECTIVE EMPLOYEE <br /> <br />AU6 1 2 1993 <br /> <br />The development of this project and the creation of these jobs are being assisted with <br />Community Development Block Grant (CDBG) funds provided to us from the City of Elk River, <br />\\..ILY/l.O) <br />which it receives from the M N Department of Trade and Economic Development. A <br />requirement of this assistance is that we collect data on the sex, ethnicity and income of <br />persons who apply for employment. Therefore, we ask that you answer the questions below. <br />This information will not be disclosed or released by this office without your consent, <br />except to the City of Elk River and to M N Department of Trade and Economic Development <br />(C IcY I ~o i <br />(DTED) and except as required or permitted by law. <br />Are you .......... _Male _Female Female Head of Household <br />Are you ......................... White (not Hispanic 1 <br />"'--Black (not Hispanic <br />-American Indian or Alaskan Native <br />--Hispanic <br />Asian or Pacific Islander <br />Were you referred by ........ Jobs Training Partnership Act (JTPA) <br />m- -rtlJ <br /> <br />A. TAKEN BY: <br /> <br />What is the number of adults and children living in your household including <br />yourself?_ <br /> <br />For the past year what was the total family income (before taxes) for all members of your <br />household? Please check the appropriate response across from the family size <br />you listed aoov~. <br /> <br />LOW-INCOME <br /> <br />LMI <br /> <br />NON-LMI <br />12"1''151 or more <br />~\I qOI or more <br />~' or more <br />or more <br />U or more <br />or more <br />o or more <br />1 or more <br /> <br />I member: $ 11,850 or less, 11 aSI - :z.1,l!~O <br />2 members: $zoO.tWO or less, 2.0,llOI - :?,/,qOO <br />3 mem bers: $ "Z.2.,q"O or less, n,q51 - ~lqOO <br />4 members: :z."','SOO or less, 2.5.501 - Zd. qOO , <br />5 members: "1 50 or less, 1-1.551. - <11.'00 <br />6 members: 7.q,,,,OO or less, $2.~,bOI : ~~iffi'" <br />7 members: "","00 or less, 3'.bt>1 <br />8 members: '!>'>;,1050 or less, $"!,';//t)c, I -:z. , <br />If requested, I would agree to make my financial records available to the <br />Cirl of Elk River or DTED for verification of the above information. <br />( 11,.11 L.oJ <br /> <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 /> <br />S IY!ldL..Uf1: <br /> <br />DdLf: <br /> <br />Wamin~: Section 1001 of Title 18 of the United States Code (Criminal Code and <br />Crimina, h cedure) shall apply to the foregoing certification. Title 18 provides, among <br />other things, that whoever, knowingly and willingly makes or uses a document or writing <br />containing any false, fictitious or fraudulent statement or entry, in al1Y manner within <br />the jlj,risCIictlon of any department or agency of the United States, shan be fined more <br />than UO,OOO or imprisoned not more than five years, or both. <br /> <br />I Prospective Employee Stop Here <br />