<p>MOH SECTION 3 PROGRAM CITY AND COUNTY OF SAN FRANCISCO FOR HUD FUNDED PROJECTS EDWIN M. LEE, MAYOR MAYOR’S OFFICE OF HOUSING OFFICE OF ECONOMIC AND WORKFORCE DEVELOPMENT</p><p>EXHIBIT F: “SECTION 3” ELIGIBILITY CERTIFICATION FORM</p><p>The United States Department of Housing and Urban Development (HUD) monitors our hiring practices on “Section 3” funded projects. It is important, therefore, that the information below be provided. Please be aware that your response, though needed, is voluntary and has no affect on your employment status. Because these questions are personal in nature, your answers will be treated with confidentiality. Thank you for assisting us. Sincerely, San Francisco Mayor’s Office of Housing</p><p>I. Employee Information:</p><p>Name: Position/Title: Hire Date: Are you currently employed? Yes No Address: Do you live in Public Housing or Section 8 Participant? Yes No Did you graduate from YouthBuild, CityBuild/CBO program? Yes No Are you currently homeless or formerly homeless? Yes No City: Zip: Are you currently on Public Assistance? (Food Stamps,etc.) Yes No Are you a Veteran or recent college graduate? Yes No Are you a Single Mother re-entering the workforce? Yes No Are you an apprentice? Yes No </p><p>II. Income Information: Circle only one box below. Family of: 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons less than less than less than less than less than less than less than less than 30% of Median $23,250 $26,600 $29,900 $33,200 $35,900 $38,550 $41,200 $43,850</p><p>$23,251 - $26,601 - $29,901 - $33,201 - $35,901 - $38,551 - $41,201 - $43,851 - Very Low Income $38,750 $44,300 $49,850 $55,350 $59,800 $64,250 $68,650 $73,100</p><p>$38,751 - $44,301 - $49,851 - $55,351 - $59,801 - $64,251 - $68,651 - $73,101 - Low Income $62,050 $70,900 $79,750 $88,600 $95,700 $102,800 $109,900 $117,000 $62,051 $70,901 $79,751 $88,601 $95,701 $102,801 $109,901 $117,001 Moderate Income or greater or greater or greater or greater or greater or greater or greater or greater</p><p>I certify that the statements made on this sheet are true, complete and correct to the best knowledge and belief, and made in good faith.</p><p>Signature: Date: </p><p>III. Employer Information:</p><p>Company Name Street Address</p><p>Name of Representative Title City Zip Email</p><p>CityBuild Use Only IV. Section 3 Certification:</p><p>Name: . Position/Title: . Date: Certified Low Income San Francisco Metropolitan Resident? Yes No Organization: . Provided Evidence for Section 3 Hiring Preference? Yes No Address: . Zip: . Signature: ______</p>