ࡱ> W[V] fbjbj\\ 5V6i6i%@T T 83T333334666666$[ #ZZ33oF334438A0Tj 0##&#4ZZf#T Y : TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET CUMBERLAND COUNTY PORTLAND METRO AREA (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 26,800___ 26,801 44,650____ 44,651 68,500____ Above 68,5012____ Below 30,600___ 30,601 51,000____ 51,001 78,250____ Above 78,2513____ Below 34,450___ 34,451 57,400____ 57,401 88,050____ Above 88,0514____ Below 38,250___ 38,251 63,750____ 63,751 97,800____ Above 97,8015____ Below 41,350___ 41,351 68,850___ 68,851 105,650____ Above 105,6516____ Below 44,400___ 44,401 73,950___ 73,951 113,450___ Above 113,4517____ Below 47,450___ 47,451 79,050___ 79,051 121,300____ Above 121,3018____ Below 52,720___ 52,721 84,150____ 84,151 -129,100____ Above 129,101 Cape Elizabeth, Casco, Chebeague Island, Cumberland, Falmouth, Freeport, Frye Island Gorham, Gray, Long Island, North Yarmouth, Portland, Raymond, Scarborough, South Portland, Standish, and Westbrook. 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? 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  ?Pfg ! >  4 5    ⶧xr`QCh}CJOJQJ^JaJh}CJOJQJ\^JaJ#h}5>*CJOJQJ\^JaJ h}CJh}CJOJQJ^Jh}5CJOJQJ^J h}0Jh}0JCJOJQJ^JaJh}0J>*CJOJQJ^Jh}0JCJOJQJ^Jh}0JCJOJQJ^JaJhhLCJOJQJ^JaJh}CJOJQJ^JaJh}5CJOJQJ^JaJ ?g 5  & 3 T $$&`#$/Ifa$b$gd}`$a$$a$ & 3 T U V Z ^ b l m o z { | } ~  ŷ勺勺hK[CJOJQJ^JaJhE[CJOJQJ^JaJhq'CJOJQJ^JaJhkCJOJQJ^JaJh0,CJOJQJ^JaJ h}h}CJOJQJ^JaJBT U V Z ^ b l hhhhh$$&`#$/Ifa$b$gd}kd$$Ifl0Q%p  t 6`644 l` ae4pyt2wl m %kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~um o $$&`#$/Ifa$b$gdO$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd} %kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u $$&`#$/Ifa$b$gd$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd}      !%&'()*+./01345:;<=?ABCDEFӷӷӷӷӷӷөӷhOCJOJQJ^JaJhK[CJOJQJ^JaJhE[CJOJQJ^JaJ h}h}CJOJQJ^JaJh0,CJOJQJ^JaJhkCJOJQJ^JaJB  %kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u !5J\$$&`#$/Ifa$b$gd$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd}FGHIJUVWXYZ[\]_jklmopquvwxz{|}~ŷŷ֛ŷ֛ōś֛ōhCJOJQJ^JaJhkCJOJQJ^JaJhTCJOJQJ^JaJhK[CJOJQJ^JaJ h}h}CJOJQJ^JaJh0,CJOJQJ^JaJhq'CJOJQJ^JaJhE[CJOJQJ^JaJ7\]%kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u]_q$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd}  ䷩ӷӍhO?|CJOJQJ^JaJh/ CJOJQJ^JaJhE[CJOJQJ^JaJh~uCJOJQJ^JaJhCJOJQJ^JaJhkCJOJQJ^JaJ h}h}CJOJQJ^JaJh0,CJOJQJ^JaJhq'CJOJQJ^JaJ2%kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u$$&`#$/Ifa$b$gd$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd}%kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u'<P$$&`#$/Ifa$b$gd$$&`#$/Ifa$b$gdxK$$&`#$/Ifa$b$gdO$&`#$/Ifb$gd}  "#$%&'+-./012345789:;<?AHIKLMNOPQS^_`acdeijklmŷũ䩷ũ䩷֩֩śśŷhTCJOJQJ^JaJhE[CJOJQJ^JaJhO?|CJOJQJ^JaJ h}h}CJOJQJ^JaJh~uCJOJQJ^JaJh0,CJOJQJ^JaJhkCJOJQJ^JaJ=PQ%kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~uQSey$$&`#$/Ifa$b$gd$$&`#$/Ifa$b$gdxK$&`#$/Ifb$gd}mnrstuvwxy}~ŷӷŷөŷŷŷᗅ#hO?|h}>*CJOJQJ^JaJ#hO?|hO?|>*CJOJQJ^JaJh~uCJOJQJ^JaJh0,CJOJQJ^JaJhE[CJOJQJ^JaJhO?|CJOJQJ^JaJ h}h}CJOJQJ^JaJhkCJOJQJ^JaJ.%kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~u$&`#$/Ifb$gd0,$$&`#$/Ifa$b$gdxK$$&`#$/Ifa$b$gd$&`#$/Ifb$gd}.0:<DFNP[\bdַַַַhhLCJOJQJ^JaJh}CJOJQJ^JaJhCJOJQJ^JaJh}CJOJQJ^J h}h}CJOJQJ^JaJhO?|CJOJQJ^JaJh0,CJOJQJ^JaJhE[CJOJQJ^JaJhCJOJQJ^JaJ2%##kd$$IflrQk%BV  t 6`2644 l` ae4p2yt~udhj345_`s567BCŴsssţsssddUdsh}5CJOJQJ^JaJh}5CJOJQJ^JaJh}CJOJQJ^JaJh}CJaJh}0JCJOJQJ^Jh}0JOJQJ^J h}0J5>*CJOJQJ^J h}5>*CJOJQJ^JaJh}CJOJQJ^JaJ!hhL0J>*CJOJQJ^JaJh}CJOJQJ^JaJhhLCJOJQJ^JaJ!45_`56BCb%'(*7$8$H$b$%&'()*+,-./019:=>?QTXYbcdefʼʮʠʋhU h~hUhO?|CJOJQJ^JaJhE[CJOJQJ^JaJh CJOJQJ^JaJh1tFCJOJQJ^JaJh~CJOJQJ^JaJhVjhVUh}CJOJQJ^JaJh}CJOJQJ^JaJ!*+-.01bcdefgd~ 3&P1h0= /! " #$% $$If!vh#v#vp:V l  t 6`655p` e4pyt2w$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~u$$If!vh#v#vB#v#vV:V l  t 6`2655B55V` e4p2yt~ux2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List *W * Strong5\@@  Balloon Text CJ^JaJ@O@ Default Text OJQJaJNo!N InitialStyle@CJOJQJ^Jo(phj3j  Table Grid7:V04B4 Header  !4 @R4 Footer  !>/a> ~ 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 f0V ???B F mdf "%')T l m  \]PQ*f  !#$&(*8@0(  B S  ?%'(*+-.01dg  %'(*+-.01dg333 FGVWXY5789IKLM$$%%'((*+-.01bdg FGVWXY5789IKLM$$%%'((*+-.01bdg1tg*54/ P?u!d#0,`5[EsqF1tFxKO Wuc~u2wg{O?|[|f3FU}b86S ]hL1t~K[ q'1hVyGE[!17TjUqkb%'@f@UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"h-KŇ-KŇS   ! x203Q@P ?h2!xx ! TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@e@d24g@Nm;0@Nm;0  ՜.+,D՜.+,t0 px  State of fb88 Document  TOWN/CITY OF __________________ Title0ContentTypeId$_ip_UnifiedCompliancePolicyUIAction&_ip_UnifiedCompliancePolicyProperties,0x01010033C4206EE50E4144A72F742A5CACF60E  !"#$%&'()*+-./012356789:;<=>?@ABCDEGHIJKLMOPQRSTUXYZy]v_`abcdefghijklmnopqrstuwxzRoot Entry F A0\ Data ,1Table4#WordDocument5VSummaryInformation(FDocumentSummaryInformation8NMsoDataStore MA08A0FUDMFSEKTC34L2==2MA0ŸA0Item  PropertiesOMOBC2UEZQQ==2 MA0A0Item  ^.Properties REPKRUOHQJEQWYA==2MA08A0Item 2Properties"U  !#$%&')DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. metaAttributes"/> CompObj(r  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q