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PRE - EMPLOYMENT <br /> HOUSEHOLD INCOME VERIFICATION FORM <br /> NAME OF JOB APPLICANT <br /> PHONE <br /> HOME <br /> ADDRESS <br /> MAILING <br /> ADDRESS <br /> NUMBER OF PERSONS LIVING AT THE ABOVE HOME ADDRESS <br /> BASED UPON THE NUMBER OF PERSONS IN YOUR HOUSEHOLD , PLEASE STATE WHETHER THE <br /> INCOME FOR YOUR HOUSEHOLD WAS BELOW THE SPECIFIED RANGE DURING THE LAST <br /> TWELVE MONTHS , <br /> NUMBER OF PERSONS IN INCOME RANGE <br /> HOUSEHOLD WAS YOUR INCOME <br /> BELOW THIS RANGE <br /> 1 $ 0 . 00 TO $ 29 , 350 <br /> 2 $ 0 . 00 TO $ 33 , 550 Yes No <br /> 3 $ 0 . 00 TO $ 37, 750 Yes No <br /> 4 $ 0 . 00 TO $ 41 , 900 Yes No <br /> 5 $ 0 . 00 TO $ 45 ,250 Yes No <br /> 6 Yes No <br /> $ 0 .00 TO $ 48 , 650 <br /> 7 Yes No <br /> $ 0 . 00 TO $ 52 , 000 <br /> 8 Yes No <br /> $ 0 . 00 TO $ 55 , 350 <br /> Yes No <br /> Please Indicate how many people in each of the following categories reside in the household . Some <br /> household members may need to be counted in more than one category. <br /> American Indian/Alaskan Native <br /> Asian or Pacific Islander Female Head of Household _ <br /> Black , Non- Hispanic Handicapped <br /> Elderly (60+) Hispanic <br /> White , Non-Hispanic <br /> Hasidic Jew <br /> The above information is required by the federal government solely to monitor compliance <br /> with equal opportunity employment laws and will not be used for other purposes. Should a <br /> job applicant decline to disclose the above information, the employer is required to note <br /> race and sex based on visual observation or surname. <br /> I affirm that the information stated on this form is true and accurately reflects the composition and income data of the <br /> household in which I reside . <br /> JOB APPLICANT 'S SIGNATURE DATE <br /> Indian River County <br />