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1 Cayuga County Health Department – Environmental Division Septic System Inspection Voucher Program Instructions: Please answer the following questions completely and to the best of your ability: Part I Applicant’s Name Address City State Zip Phone number: e-mail Co-Applicant’s Name Address City State Zip Phone number: e-mail Part II Please note that for the purpose of determining family income, the term “family” means a group of individuals who are living together as one economic unity. Total Number of people in your “family” Name Age Relationship to you Part III Does anyone in the “family” receive income from any of the following sources? If so, check the box indicating the source. Use the full name of the family member(s), the GROSS income amount (before taxes). For self-employed individuals insert the Net Income (after business expenses) in the amount column. Indicate whether the income frequency is weekly, or yearly. Source Family Member Amount Income Frequency Public Assistance/AFDC/SSI $ per $ per $ per Wages/Salary $ per $ per $ per Name & Address of Employer: Self-Employment $ per $ per *Other – Please Specify $ per $ per Part IV I (we) hereby certify that all the above information is true and correct. I (we) understand the following: • This information is being given in connection with the receipt of grant funds. • Program officials may verify the information on this form. • Deliberate misrepresentation of information may subject me (us) to repayment of grant monies received from the Cayuga County Health Department. Signature Date Signature Date ---PAGE BREAK--- 2 Cayuga County Health Department – Environmental Division Septic System Inspection Voucher Program PERSONAL PRIVACY PROTECTION LAW NOTIFICATION Required by New York State Public Officers Law, Article 6-A, Section 94.1 This information which you are providing on this application is being requested for the sole purpose of determining the eligibility of applicant(s) to obtain grant monies for a routine inspection of our septic system as required under the sanitary code. *Includes, but is not limited to interest, dividends, rental income, income from estates or trusts, foster child payments, unemployment insurance, social security, disability, spousal support, child support, pensions, and any other cash received or withdrawn from any source.