Please complete and submit this form.*

Questions about this form? Contact the City Clerk's Office at cityclerk@hyattsville.org or 301-985-5009

*Members are eligible to receive $40 per meeting attended effective December 1, 2022. Youth members may elect to receive SSL hours instead of payment. Your decision to choose to receive payment, or not, will not be shared with other members.

Payments will be mailed semi annually in June and January. Approved meeting minutes submitted to committees@hyattsville.org will provide proof of attendance at meetings.

Full Name:*

Name of board, committee, or commission you serve on. If you serve on multiple bodies, list all bodies served on (please note, payments will not exceed $600 annually regardless of service on multiple advisory bodies):

Code Compliance Advisory Committee Education Advisory Committee Educational Facilities Task Force Ethics Commission Health, Wellness, and Recreation Advisory Committee Hyattsville Environment Committee

Planning Committee Police and Public Safety Citizens' Advisory Committee Race & Equity Task Force Shade Tree Board Youth Advisory Council

If you serve on an Ad Hoc committee or task force not listed here, please enter the name here:

Phone Number:*

Email Address:*

Mailing Address:*

The City will consider all appointed members as participants in the stipend program. However, to complete enrollment you must fill out a W-9 form. Your enrollment will not be complete and you will not receive payment if the W-9 form is not submitted. Please note, a Social Security Number or Federal Tax ID is required by federal law to complete the form.

Please click on the W-9 form link to the right prior to submitting this form. The W-9 link is also available on the City's website at hyattsville.org/committees.

W-9 FORM

Payment Selection: (Please select from one of the three options in the dropdown list below)*

I agree to accept payment for my service. I am a student and elect to receive SSL hours for my service instead of payment. I do NOT wish to receive payment for my service on a City advisory body.

Please answer the following demographic questions. The City of Hyattsville is committed to appointing dedicated, diverse, individuals to these Committees to achieve membership with residents of all ages, interests, and backgrounds. Although these questions are not required for the completion of this enrollment form, it is useful for the city for the purpose of measuring outcomes. This information is for internal use only and the data is not shared publicly.

Please indicate your age range.

Under 18 18-35 36-64

Over 65 I prefer not to answer this question

Please indicate your gender(s). Select all that apply.

Man Woman Non-binary

Transgender Another option not listed here I prefer not to answer this question

Please indicate your race-ethinicity(ies). Select all that apply.

American Indian or Alaska Native Asian or Asian American Black or African American Hispanic, Latino, Latina, or Latinx Middle Eastern or Northern African

Native Hawaiian or Other Pacific Islander White Another option not listed here I prefer not to answer this question

Do you speak a language other than English at home?

Yes No

I prefer not to answer this question

If you speak a language other than English at home, what language do you speak?

Do you identify as having a disability as defined under the ADA [Americans with Disabilities Act]?

Yes No

I prefer not to answer this question

Please check which of the following best describe your household income last year:

$0-$30,000 $31,000-$60,000 $61,000-$90,000

$91,000-$120,000 $120,000+ I prefer not to answer

Which of the best describes your housing status:

I am currently unhoused (including being between addresses or couch surfing) I am currently a homeowner

I currently rent or sublease an apartment