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2022 City of Dubuque Income Verification Form

  1. To qualify for assistance for City of Dubuque Leisure Services programs you must live within the city limits of Dubuque and meet the income requirements established by The Department of Housing and Urban Development (HUD). 

  2. Applicant Information
  3. Income Verification
  4. Household Members

    Please provide the following information for the members of your household. Note, the gender, race, and ethnicity fields are optional. To provide the most equitable services possible, we would like to know more detailed information on who participates in our programs.

  5. Person 1
  6. 1d. Gender
  7. 1e. Race
  8. 1f. Ethnicity
  9. Person 2
  10. 2d. Gender
  11. 2e. Race
  12. 2f. Ethnicity
  13. Person 3
  14. 3d. Gender
  15. 3e. Race
  16. 3f. Ethnicity
  17. Person 4
  18. 4d. Gender
  19. 4e. Race
  20. 4f. Ethnicity
  21. Person 5
  22. 5d. Gender
  23. 5e. Race
  24. 5f. Ethnicity
  25. Person 6
  26. 6d. Gender
  27. 6e. Race
  28. 6f. Ethnicity
  29. Person 7
  30. 7d. Gender
  31. 7e. Race
  32. 7f. Ethnicity
  33. Person 8
  34. 8d. Gender
  35. 8e. Race
  36. 8f. Ethnicity
  37. WARNING: Whoever, knowingly and willingly makes or uses a document or writing containing any false fictitious or fraudulent statement or entry may be subject to federal prosecution.

  38. Leave This Blank:

  39. This field is not part of the form submission.