Demographic Certification

Demographic Certification
The information collected on this form is required so that Bridges Healthcare can receive Federal funds to assist in offering our programs and activities. The information you provide is completely confidential and will only be combined in summary level reporting.
Date*

MonthDayYear
Date
Client Name: *

First NameLast Name
Student?

Yes, Part-timeYes, Full-timeNo
Age:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a U.S. Citizen?

YesNo
If no, please advise immigration status:
Household Characteristics
Does your Household Rent or Own?*

RentOwn
What Gender does the Head of Household use to Identify themselves?*

MaleFemaleTransgender MaleTransgender FemaleGender Non-Binary
Total number of persons in the Household:*
Number of persons under age 18 in the Household:*
Number of males in Household:
Number of females in Household:
Number of transgender or gender non-binary persons in Household:
Number of persons 62 years of Age or older in Household:
Number of Disabled persons in Household:

For each member of your Household, please indicate their Student Status and Age:

Household Ethnicity and Annual Income
Our Household Ethnicity is:

White, not LatinoHispanic/LatinoAfrican AmericanAsianAmerican Indian/Alaskan NativeAmerican Indian/Alaskan Native & African AmericanAmerican Indian/Alaskan Native & WhiteNative Hawaiian/Other Pacific IslanderOther or Multi-Ethnic
Household Annual Income Certification

Please combine the Annual Adjusted Gross Income (AGI) before deductions for each household member over 18 years of age. Do not include Full-time student income.

NOTE: Income Limits by Household Size below are Based on 80%, 50%, 30% Area Median Income as of 4/26/2022
Our Total Household Annual Income is:*

$0 to$34,100$34,101 to $39,600$39,601 to $56,800$56,801 to $62,600$62,601 to $89,400$89,401 to $118,050$118,051 and above
Certification

On behalf of my / our household, I/we hereby certify the information provided on this form is complete and correct to the best of my/our knowledge.
Signature of Client or Head of Household*

Clear
The information collected on this form is required so that Bridges Healthcare can receive Federal funds to assist in offering our programs and activities. The information you provide is completely confidential and will only be combined in summary level reporting.
Should be Empty: