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?
Age:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a U.S. Citizen?
If no, please advise immigration status:
Household Characteristics
Does your Household Rent or Own?
What Gender does the Head of Household use to Identify themselves?
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:
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:
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
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: