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EVERETT <br /> Nlt. MjI JM <br /> Exhibit "D" <br /> SECTION C. Please complete this section for your first reporting period only. <br /> Please circle below the number of people in your household, including yourself: <br /> #of Occupants Maximum #of Occupants Maximum <br /> Annual Income Annual Income <br /> 1-Person $66,700 5-Person $102,900 <br /> 2-Person $76,200 6-Person $110,500 <br /> 3-Person $85,750 7-Person $118,150 <br /> 4-Person $95,250 8-Person $127,750 <br /> Was your total household income during the last 12 months higher or lower than the amount below the <br /> number you circled? Please circle one: HIGHER OR LOWER <br /> We may ask you to provide documentation of your income via your latest tax return or quarterly tax. <br /> Please provide your annual income from your most recent tax return : <br /> Year of Return: <br /> Has your income changed as a result of the Coronavirus Pandemic? If so, please provide an explanation <br /> and newly expect household income. <br /> Please circle one: HIGHER OR LOWER <br /> SECTION D. <br /> Please circle the appropriate race category and Hispanic ethnicity if applicable. (optional): <br /> 1. White 6. Black/African American <br /> 2. Asian 7. American Indian/Alaskan Native <br /> 3. Native Hawaiian/Other Pacific Islander 8. American Indian/Alaskan Native&White <br /> 4. Asian &White 9. Black/African American & White <br /> 5. American Indian/Alaskan Native 10. Other Multi Racial <br /> & Black/African American <br /> Hispanic ethnicity if appropriate: Hispanic/Not Hispanic Female Headed Household? Yes No <br /> SECTION E. <br /> Please list the positions CURRENTLY employed by you: <br /> Position First Name Only Part Time/ Full Time <br /> 1Business Owner/ <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> Page 2 of 3 <br />