Exhibit F-1

EXHIBIT F-1 STATEMENT OF ELIGIBILITY

LIMITED CLIENTELE - INCOME DATA MAINTAINED

Activity Date

Client Name:

Service/s Requested:

Address:

Zipcode

Phone #:

Birth Date:

Date

Age

Is the Service Recipient/Client a Single Female Head of Household (i.e., a single female parent with a child 18 years old or younger)?

YesNo

Race and Ethnicity: **Must check ONE of the first two lines below THEN choose the appropriate race category:category:

Exhibit F, Statement of Eligibility, Limited Clientele Income Data Maintained Page 1 of 5

HR&D 2019-2020 CDBG/NOF PUBLIC SERVICE CONTRACT