BACK TO SCHOOL APPLICATION - INCOME

Income Check one:
Annually-yearly   
Bi-weekly-every two weeks   
Weekly*   

I Name* attest that my income is   $*   

I understand that each time I visit Community Action of Greene County, Inc., I will be asked if my income status has changed.

I understand that I may be asked to provide income documentation (to include pay stubs, benefit letters, social security, child support, etc.) at a future date.

Client Signed:   Signature*   
Date:  Date*   

CAGC Staff Witness:   Signature  
Date:   Date    

Contact Information:
Name:   First Name*   Last Name*        
Phone:    Area Code*   Phone Number*   
Email:  Email   

Household size:   Please Select123456789+*   
Number of Adults:   Please Select123456789+   
Number of Children:   Please Select123456789+*