ࡱ> DFC] Jbjbj\\ 7<6i6i Juuuuu8|= "YYYYY444       $"f%3 u444443 uuYYH (((4RuYuY (4 (( Y3#^ 0 ,&Dr& &u 44(444443 3 r444 4444&444444444Y ;: TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET ANDROSCOGGIN COUNTY (Uses Lewiston/Auburn MSA) Date: ___________ CDBG EDP SURVEY #: ___________ The Town/City of has been awarded Community Development Block Grant (CDBG) funds from the State of fb88, Department of Economic and Community Development. The proposed activities are: For the proposed activities, the CDBG program requires documentation of program benefit. Therefore, the community is surveying the potential beneficiaries ensuring compliance with CDBG program regulations. Your response to the following questions is critical for meeting CDBG program requirements. All responses are confidential and used solely for securing CDBG grant funds. THIS INFORMATION WILL BE KEPT CONFIDENTIAL. Please return this form to __________________________________________ as soon as possible. If you have questions, please contact _______________________________________ Thank you for your cooperation. ============================================================================================================ In determining total family income use your total gross income for the 12 month period prior to completing this form. FAMILY SIZE: FAMILY INCOME: (Please Circle one) (Please check one) 30% 50% 80% Above 80% 1 ____ Below 17,300 ____ 17,301 - 28,850 ____ 28,851 46,150 ____ Above 46,151 2 ____ Below 20,440 ____ 20,441 - 33,000 ____ 33,001 52,750 ____ Above 52,751 3 ____ Below 25,820 ____ 25,821 - 37,100 ____ 37,101 59,350 ____ Above 59,351 4 ____ Below 31,200 ____ 31,201 - 41,200 ____ 41,201 65,900 ____ Above 65,901 5 ____ Below 36,580 ____ 36,581 - 44,500 ____ 44,501 71,200 ____ Above 71,201 6 ____ Below 41,960 ____ 41,961 - 47,800 ____ 47,801 76,450 ____ Above 76,451 7 ____ Below 47,340 ____ 47,341 - 51,100 ____ 51,101 - 81,750 ____ Above 81,751 8 ____ Below 52,720 ____ 52,721 54,400 ____ 54,401 - 87,000 ____ Above 87,001 *The FY 2014 Consolidated Appropriations Act changed the definition of extremely low income. Consequently the 30% income limits may equal the 50% income limits BENEFICIARY INFORMATION: Individual Race: Indicate by placing an "X" on the appropriate line: White ___ Black/African American ___ Asian ___ American Indian/Alaskan Native ___ Native Hawaiian/Other Pacific Islander ___ Asian & White ___ American Indian/Alaskan Native & White ___ Black/African American & White ___ American Indian/Alaskan Native & Black/African American ___ Other ___ Individual Make-up: Indicate by placing an X on the appropriate lines: Elderly: ___ Severely Disabled: ___ Female Head of Household? Yes ___ No ____ Before taking this job were you employed? Yes ___ No ___ I certify that the information on this survey form is true and complete to the best of my knowledge and belief, and that the Town/City of ______________, the State of fb88, and the Federal Government are hereby authorized to verify the information contained herein. ____________________________________________________________________________________________________________________ Signature Printed Name Date ================================================================================================================================== TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI ___ NON-LMI___ ________________________________________________________________________________________ Signature of authorized official Date     Revised 4/2024 Effective 4/1/2024  ?Snm S T d  & ( ƸzhYJJh\s>*CJOJQJ^JaJh\s>*CJOJQJ^JaJ#h\s5>*CJOJQJ\^JaJh\sCJOJQJ^Jh\s5CJOJQJ^J h\s0Jh\s0JCJOJQJ^JaJh\s0J>*CJOJQJ^Jh\s0JCJOJQJ^Jh\sCJOJQJ^JaJh\sCJOJQJ^JaJh\sCJOJQJ^JaJh\s5CJOJQJ^JaJ ?Sn S T d ( G HTgd`m` -DM `$a$( + G U V W X Z [ b c d f g k l m n o p v w x y z { |  ֺȬȬ䬺Ȭ䐂䐂Ȭth`m`CJOJQJ^JaJhCCJOJQJ^JaJhBCJOJQJ^JaJhCJOJQJ^JaJh.G4CJOJQJ^JaJh ]VCJOJQJ^JaJh'JCJOJQJ^JaJhnCJOJQJ^JaJh\sCJOJQJ^JaJh\sCJOJQJ^JaJ) ииppXX. *hCCJOJQJ^JaJfHq . *hXkCJOJQJ^JaJfHq . *hBCJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *h.G4CJOJQJ^JaJfHq . *h'JCJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq   &ӽӽ}o}a}o}SoS}Sh.G4CJOJQJ^JaJhr CJOJQJ^JaJhXkCJOJQJ^JaJh ]VCJOJQJ^JaJh_>(CJOJQJ^JaJh\sCJOJQJ^JaJ+h\sCJOJQJ^JaJfHq +h.G4CJOJQJ^JaJfHq +hCCJOJQJ^JaJfHq +hBCJOJQJ^JaJfHq &'()+/12345ACDEFGHVWXYZ[efgijlȺȺȆnVVnnVVn. *h ]VCJOJQJ^JaJfHq . *hXkCJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq hBCJOJQJ^JaJh.G4CJOJQJ^JaJhCCJOJQJ^JaJh\sCJOJQJ^JaJh ]VCJOJQJ^JaJhXkCJOJQJ^JaJh)iCJOJQJ^JaJlnopqs|}~и蠸踈pXXB+h CJOJQJ^JaJfHq . *hCCJOJQJ^JaJfHq . *h CJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq . *h1CJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *hXkCJOJQJ^JaJfHq . *h.G4CJOJQJ^JaJfHq 齧}}}}oa}S}a}S}Sh1CJOJQJ^JaJh CJOJQJ^JaJh.G4CJOJQJ^JaJh ]VCJOJQJ^JaJhQ5CJOJQJ^JaJh\sCJOJQJ^JaJ+h\sCJOJQJ^JaJfHq +h\sCJOJQJ^JaJfHq +h.G4CJOJQJ^JaJfHq +hCCJOJQJ^JaJfHq     ְeeJ4 *h h\sCJOJQJ^JaJfHq 4 *h h)iCJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *h1CJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq h1CJOJQJ^JaJh\sCJOJQJ^JaJh.G4CJOJQJ^JaJhCCJOJQJ^JaJ !"#$%/0123489:;<=MиРиРpXX@. *h1CJOJQJ^JaJfHq . *hCCJOJQJ^JaJfHq . *hCJOJQJ^JaJfHq . *hCJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *h CJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq . *h.G4CJOJQJ^JaJfHq MNOPQRTbcdegqrstvz{|}~ӽӧ}}}o}oa}o}SEh CJOJQJ^JaJhCJOJQJ^JaJh1CJOJQJ^JaJh.G4CJOJQJ^JaJh ]VCJOJQJ^JaJhCJOJQJ^JaJh\sCJOJQJ^JaJ+h1CJOJQJ^JaJfHq +h\sCJOJQJ^JaJfHq +hCCJOJQJ^JaJfHq +hCJOJQJ^JaJfHq Ⱥ֬|dLd. *h.G4CJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *hCJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq h.G4CJOJQJ^JaJhCJOJQJ^JaJhCCJOJQJ^JaJh1CJOJQJ^JaJh\sCJOJQJ^JaJh%|CJOJQJ^JaJиpXpXXpиppиp. *h.G4CJOJQJ^JaJfHq . *hCCJOJQJ^JaJfHq . *h`m`CJOJQJ^JaJfHq . *h ]VCJOJQJ^JaJfHq . *hCJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq . *hCJOJQJ^JaJfHq !9:Mijwi[[[iwS[i[DDh\s5CJOJQJ^JaJh\sCJaJh\sCJOJQJ^JaJh\sCJOJQJ^JaJh\s0JCJOJQJ^Jh\s0JOJQJ^J h\s0J5>*CJOJQJ^J h\s5>*CJOJQJ^JaJ h`m`5>*CJOJQJ^JaJh`m`CJOJQJ^JaJ+h\sCJOJQJ^JaJfHq . *h\sCJOJQJ^JaJfHq 9:<y    <xy     14589BŷӷzllzlhCCJOJQJ^JaJh CJOJQJ^JaJh9HCJOJQJ^JaJ h.3h.3CJOJQJ^JaJhChhFjhhFUh\sCJOJQJ^JaJh\sCJOJQJ^JaJh\sCJOJQJ^JaJh\s5CJOJQJ^JaJh\s5CJOJQJ^JaJ&BCDEFGHIJgdgd.3 BCDEFGHIJh\sCJOJQJ^JaJhhFhCh\sh/Q> .3 Footer CharCJOJQJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  O4׹ӧCvHa01 %xz24ĥ=m X\(7Xjg !Ӆqd? cG7.`~w*?, 2 nN*"Fz_&n &\ F:l[+%f J0< EGIL( &lMBJ J 8@0(  B S  ?   HKnw    AHK333333333ACDE9:;<NOPQ   BDHKACDE9:;<NOPQ   BDHK73.^`OJPJQJ^Jo(^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hH73+        65m|9 /  "F%_>(.G4:LHAhF'Jm(P ]VbXo^`m`2bzx@ƨ#@ƨ#  ՜.+,0 hp  State of fb88   TOWN/CITY OF __________________ Title  !"#$%&'()*+,-./012456789:<=>?@ABERoot Entry F 3#G1Table&WordDocument7<SummaryInformation(3DocumentSummaryInformation8;CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q