ࡱ> =?<] bjbj\\ 526i6iH @uuuuu8d%99999$w!uuu99Fu9u99M9<Zv0"x""uH~"Y ;: TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET KNOX COUNTY 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 19,250 ____ 19,251 - 32,100 ____ 32,101-- 51,350 ____ Above 51,351 2 ____ Below 22,000 ____ 22,001 - 36,650 ____ 36,651 58,650 ____ Above 58,651 3 ____ Below 25,820 ____ 25,821 - 41,250 ____ 41,251 - 66,000 ____ Above 66,001 4 ____ Below 31,200 ____ 31,201 - 45,800 ____ 45,801 - 73,300 ____ Above 73,301 5 ____ Below 36,580 ____ 36,581- 49,500 ____ 49,501 - 79,200 ____ Above 79,201 6 ____ Below 41,960 ____ 41,961 - 53,150 ____ 53,151 - 85,050 ____ Above 85,051 7 ____ Below 47,340 ____ 47,341 - 56,800 ____ 56,801 - 90,900 ____ Above 90,901 8 ____ Below 52,720 ____ 52,721 60,500 ____ 60,501 - 96,800 ____ Above 96,801 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? 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