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2. Introduction

   We are asking your cooperation in completing this form for record keeping purposes to verify both the job retention and income benefits being provided through the City of Modesto’s Small Business Assistance Program. Please be assured that this information will remain confidential and will be used only to meet the record keeping requirements of the U.S. Department of Housing and Urban Development, which is providing the CDBG-CV funds to help retain your job.

4. Title II Compliance
   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.
6. Are you the Business Owner or an Employee?*

   1. Business Owner
   2. Employee
8. Business Name*
10. Owner Full Name*
11. Owner Phone Number*
13. Employee Full Name*
14. Employee Phone Number*
16. Address*
18. City*
19. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
20. Zip Code*
22. Job Title*
23. Is your position Full Time or Part Time?*

    1. Full-time
    2. Part-time
25. Is this a new or existing job for you?*

    1. Existing Job
    2. New Job
26. Date of Hire*
    Date of Hire
28. Household Size*
    -- Select One --12345678
29. Household Annual Income*
    Round up to the nearest dollar.
31. Head of Household*

    (Check all that apply)

    1. Female
    2. Male
    3. Transgender

    1. Veteran
    2. 62 Years or Older
    3. Disabled
32. Ethnicity*

    1. Hispanic
    2. Non-Hispanic
34. Race*

    1. White (includes any European bloodlines)
    2. American Indian/Alaskan Native (includes Native Middle and Latin American)
    3. Asian
    4. Native Hawaiian/Pacific Islander
    5. Black/African American and White

    1. Black/African American
    2. Asian and White
    3. American Indian/Alaskan Native and White
    4. American Indian/Alaskan Native and Black/Africa
    5. Other Multi-Racial
35. Other
37. Acceptance*

    Review and check the following.

    1. I hereby certify that the above information is true and correct to the best of my knowledge.
    2. I acknowledge and understand that the information provided here will be relied upon for purposes of determining my eligibility for this program.
39. Electronic Signature Agreement*

    1. I accept and consent to be legally bound by this Agreement's terms and conditions by signing below.

    By Checking "I Accept", you agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
41. Signature*
    By signing this form electronically, I acknowledge that a material misstatement fraudulently or negligently made in this or in any other statement made by me may constitute a federal violation and may result in the denial of my participation in this program.
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field