ࡱ> UXT]  bjbj\\ 5T6i6i @T T 83L+++++$q ++R+++`-+Xj0 !d !& !&d !T Y : TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET CUMBERLAND COUNTY (Select portions of Cumberland County, see list of communities below) 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 (Circle One)FAMILY INCOME (Please Check one)30%50%80%Above 80%1____ Below 21,500___ 21,501 32,550____ 32,551 - 57,200____ Above 57,2012____ Below 24,550___ 24,551 37,200____ 37,201 - 65,350____ Above 65,3513____ Below 27,600___ 27,601 41,850____ 41,851 73,550____ Above 73,5514____ Below 31,200___ 31,201 46,450____ 46,451 - 81,700____ Above 81,7015____ Below 36,580___ 36,581 50,200____ 50,201 88,250____ Above 88,2516____ Below 41,960___ 41,961 - 53,900____ 53,901 94,,800____ Above 94,8017____ Below 47,340___ 45,421 57,600____ 57,601 101,350____ Above 101,3518____ Below 52,720___ 50,561 61,350____ 61,351 107,850____ Above 107,851 Baldwin town, Bridgton town, Brunswick town, Harpswell town, Harrison town, Naples town, New Gloucester town, Pownal town, Sebago town 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 ___ 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? 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O4׹ӧCvHa01 %xz24ĥ=m X\(7Xjg !Ӆqd? cG7.`~w*?, 2 nN*"Fz_&n &\ F:l[+%f 0T ???B 4#  $')> V W FG78   !"#%&(8@0(  B S  ?\b  !  333      1tg*.-lP?ud#12`5[EsqF1tF6KxKyLOV7U3r[uc%Vs;0t2w 1wg{[|3FU}b6S ]W;it~,`1hyp"jU @ @UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"qhKŇKŇS  ! x20 3Q@P ?h2!xxf TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@0@d24g@p*@p*  ՜.+,0 hp  State of fb88   TOWN/CITY OF __________________ Title  !"#$%&'()*,-./012456789:;<=>?@ABCEFGHIJKMNOPQRSVWZRoot Entry F{+Y@Data +1Table3 !WordDocument 5TSummaryInformation(DDocumentSummaryInformation8LMsoDataStore@+`-+2EKVO0WX==2@+`-+Item  2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q