S3C-_1A_Section_3_Worker_Self_Cert_.pdf
PDF 73 KB Posted
- Solicitation number
- 2025-IFB-017
- Issued by
- Mohave County, Arizona
About this file
The document is a Section 3 Worker Self-Certification Form (S3C-1A) related to the Jerry Ambrose Veterans Council Transitional Housing Rehab - Phase II project in Kingman, Arizona. The form is designed for workers seeking preference in training and employment, requiring them to self-certify their income status in relation to the HUD income chart for their family size. Specifically, workers must confirm that their previous year's income is below 80% of the median income for their family size.
The form includes a certification statement where the worker attests to the truthfulness of the information provided and acknowledges that falsifying any details could result in disqualification and potential legal punishment. The document provides space for the worker's name, a checkbox to confirm income status, and lines for signature and date. This form appears to be part of the City of Kingman's efforts to ensure employment opportunities for low-income individuals in conjunction with the veterans housing rehabilitation project funded through a Community Development Block Grant from the Arizona Department of Housing.
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Text version
Section 3 Worker Self-Certification Form (S3C-1A)
A Section 3 Worker seeking preference in training and employment shall certify or submit evidence to the recipient, contractor, or subcontractor that the person is a Section 3 Worker, as defined in Section 24 CRF 75.
Name of Worker
I have reviewed the HUD income chart for my family size. My income for the previous year is below 80% of the median income for my family size.
I hereby certify that the information provided by me to be true and correct and understand any falsification of any of the information could subject me to disqualification from participation and punishment under the law.
Signature Date
Section 3 Worker Self-Certification Form (S3C-1A)
File details come from the government source that posted it. Updated .