ࡱ> XZW] kbjbj\\ 5X6i6i,>T T 83\33333*,,,,,,$Q #PP33eF33**3|zTv{0##&#.PPf#T Y : TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET PENOBSCOT COUNTY (Select portions of Penobscot 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 17,300___ 17,301 28,850____28,851 46,150____ Above 46,1512____ Below 20,440___ 20,441 - 33,000____ 33,001 - 52,750____ Above 52,7513____ Below 25,820___ 25,821 - 37,100____ 37,101 - 59,350____ Above 59,3514____ Below 31,200___ 31,201 41,200____ 41,201 65,900____ Above 65,9015____ Below 36,580___ 36,581 44,500____ 44,501 71,200____ Above 71,2016____ Below 41,960 ___ 41,961 - 47,800____ 47,801 76,450____ Above 76,4517____ Below 47,340 __ 47,341 51,100____ 51,101 81,750____ Above 81,7518____ Below 52,720 ___ 52,721 54,400____ 54,401 - 87,000____ Above 87,001 Alton, Argyle, Bradford, Bradley, Burlington, Carmel, Carroll plantation, Charleston, Chester, Clifton, Corinna, Corinth, Dexter, Dixmont, Drew plantation, East Central Penobscot UT, East Millinocket, Edinburg, Enfield, Etna, Exeter, Garland, Greenbush , Howland, Hudson, Kingman UT, Lagrange, Lakeville, Lee, Levant, Lincoln, Lowell, Mattawamkeag, Maxfield, Medway, Millinocket, Mount Chase, Newburgh, Newport, North Penobscot UT, Passadumkeag, Patten, Plymouth, Prentiss UT, Seboeis plantation, Springfield, Stacyville, Stetson, Twombly UT, Webster plantation, Whitney UT, Winn, Woodville *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 ___ 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  ?P y  %    ; < = A E I S T ĵĵį~oaPPPPPPPPPP hhCJOJQJ^JaJhCJOJQJ^JaJhCJOJQJ\^JaJ#h5>*CJOJQJ\^JaJ hCJhCJOJQJ^Jh5CJOJQJ^J h0Jh0J>*CJOJQJ^Jh0JCJOJQJ^Jh0JCJOJQJ^JaJhCJOJQJ^JaJh5CJOJQJ^JaJ ?P y   ; $$&`#$/Ifa$b$gd`$a$$a$ ; < = A E I S }}}}}$$&`#$/Ifa$b$gdjkd$$Ifl0Q%p t 6`644 lae4pytb- S T V h L8!$$&`#$/Ifa$b$gd+7$&`#$/Ifb$gdkd}$$IflrQk%BV t 6`644 lae4p2ytb- T V b c d f h m n o q s t u v w x y z { | ӷӛӛh`CJOJQJ^JaJhCJOJQJ^JaJhRCJOJQJ^JaJh%hCJOJQJ^JaJh*|CJOJQJ^JaJh*CJOJQJ^JaJhW&CJOJQJ^JaJhJCJOJQJ^JaJ hhCJOJQJ^JaJ2h | $$&`#$/Ifa$b$gd+7$$&`#$/Ifa$b$gd* L8!$$&`#$/Ifa$b$gd+7$&`#$/Ifb$gdkd4$$IflrQk%BV t 6`644 lae4p2ytb-     ﷩y hh]CJOJQJ^JaJh+7CJOJQJ^JaJ hh8CJOJQJ^JaJhRCJOJQJ^JaJh%hCJOJQJ^JaJh*CJOJQJ^JaJhW&CJOJQJ^JaJhJCJOJQJ^JaJ hhCJOJQJ^JaJ, $$&`#$/Ifa$b$gd* +$&`#$/Ifb$gdkd$$IflrQk%BV  t 6`2644 lae4p2yt/} 0B$$&`#$/Ifa$b$gd+7$$&`#$/Ifa$b$gd* !"#$%)*+,-.0;<=>?@BCEPQRSTUW[\]^_`bcdfghikprstuwŷŷӷӷӛӷӷŷhACJOJQJ^JaJh*CJOJQJ^JaJhW&CJOJQJ^JaJhRCJOJQJ^JaJh%hCJOJQJ^JaJ hhCJOJQJ^JaJhJCJOJQJ^JaJh]CJOJQJ^JaJ7BCEWL8!$$&`#$/Ifa$b$gd+7$&`#$/Ifb$gdkd$$IflrQk%BV t 6`644 lae4p2ytb- Wk$$&`#$/Ifa$b$gd+7wxyz{|}~ᷩᷩōōōhW&CJOJQJ^JaJh4rXCJOJQJ^JaJhJCJOJQJ^JaJh`CJOJQJ^JaJhRCJOJQJ^JaJh%hCJOJQJ^JaJ hhCJOJQJ^JaJh*CJOJQJ^JaJ7+$&`#$/Ifb$gdkd$$IflrQk%BV  t 6`2644 lae4p2yt/}5kd$$IflrQk%BV t 6`644 lae4p2ytb- $$&`#$/Ifa$b$gd+7 "4$$&`#$/Ifa$b$gd*$$&`#$/Ifa$b$gdW&$&`#$/Ifb$gd*$$&`#$/Ifa$b$gd+7$&`#$/Ifb$gd      "-./024ӦӘ|||n|||||hW&CJOJQJ^JaJhRCJOJQJ^JaJh]CJOJQJ^JaJhACJOJQJ^JaJh dCJOJQJ^JaJ hh*CJOJQJ^JaJh*CJOJQJ^JaJhJCJOJQJ^JaJh4rXCJOJQJ^JaJ hhCJOJQJ^JaJ+457BCDEGIMNOPQRSUY[\]_`eghijklmnpqrųӓwi[Ņh*CJOJQJ^JaJh!gCJOJQJ^JaJh3WCJOJQJ^JaJhRCJOJQJ^JaJh dCJOJQJ^JaJ#h]hW&>*CJOJQJ^JaJ#h]h d>*CJOJQJ^JaJhW&CJOJQJ^JaJhJCJOJQJ^JaJh]CJOJQJ^JaJ hhCJOJQJ^JaJ"457+$&`#$/Ifb$gdkdK$$IflrQk%BV  t 6`2644 lae4p2yt/}7I`u$$&`#$/Ifa$b$gd&ms$&`#$/Ifb$gd*$$&`#$/Ifa$b$gdW&rsu᳡wiwӅh*CJOJQJ^JaJh&msCJOJQJ^JaJhJCJOJQJ^JaJh>NCJOJQJ^JaJ#h]h>N>*CJOJQJ^JaJ#h]h>*CJOJQJ^JaJhW&CJOJQJ^JaJhRCJOJQJ^JaJ hhCJOJQJ^JaJh4rXCJOJQJ^JaJ)L8!$$&`#$/Ifa$b$gd>N$&`#$/Ifb$gdkdD$$IflrQk%BV t 6`644 lae4p2ytb- $$&`#$/Ifa$b$gd*$&`#$/Ifb$gd><:;<fgzᩩ|k_Q_IkQhCJaJh0JCJOJQJ^Jh0JOJQJ^J h0J5>*CJOJQJ^J h5>*CJOJQJ^JaJhCJOJQJ^JaJh&msCJOJQJ^JaJhCJOJQJ^JaJhW&CJOJQJ^JaJhCJOJQJ^JaJh4rXCJOJQJ^JaJ hhCJOJQJ^JaJhRCJOJQJ^JaJ<+)$)gd&mskd$$IflrQk%BV  t 6`2644 lae4p2yt/};<fg<HIh,./124578ghigdW&<=HIh+,-./012345678@ABEFX[\_`gꨤzllzlhRCJOJQJ^JaJhCJOJQJ^JaJh\CJOJQJ^JaJhW&CJOJQJ^JaJh^ijh^iUhCJOJQJ^JaJhCJOJQJ^JaJh5CJOJQJ^JaJh5CJOJQJ^JaJhCJOJQJ^JaJhCJaJ'ghijkhCJOJQJ^JaJh^ih hW&hijk3&P1h0= /! " #$% {$$If!vh#v#vp:V l t 6`655pe4pytb- $$If!vh#v#vB#v#vV:V l t 6`655B55Ve4p2ytb- $$If!vh#v#vB#v#vV:V l t 6`655B55Ve4p2ytb- $$If!vh#v#vB#v#vV:V l  t 6`2655B55Ve4p2yt/}$$If!vh#v#vB#v#vV:V l t 6`655B55Ve4p2ytb- $$If!vh#v#vB#v#vV:V l  t 6`2655B55Ve4p2yt/}$$If!vh#v#vB#v#vV:V l t 6`655B55Ve4p2ytb- $$If!vh#v#vB#v#vV:V l  t 6`2655B55Ve4p2yt/}$$If!vh#v#vB#v#vV:V l t 6`655B55Ve4p2ytb- $$If!vh#v#vB#v#vV:V l  t 6`2655B55Ve4p2yt/}x2 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> W& 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 k1X ===@T w4rgk  #&)*; S h BW47ik!"$%'(+8@0(  B S  ?,./124578il   ,./124578il3333*+,-<=>?z{|} ./02npqr++,,.//124578gil*+,-<=>?z{|} ./02npqr++,,.//124578ghil1tg*43b- >j%%73+7ù9!<tJ?p`K3W4rXGZgZ]` d!g%h^i gq&ms{*|WD|/}8_!.Z\JUpR4vgW&9ECH8AP=&]$*'y,.@; ; ; ; k@UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"hRŧRŧDU'i i ! x20$$3Q@P ?82!xx7Q TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@@ރ8@Z@Zi  ՜.+,0 hp  State of fb88$  TOWN/CITY OF __________________ Title  !"#$%&'()*+,./012346789:;<=>?@ABCDEFHIJKLMNPQRSTUVYRoot Entry FZz[Data -1Table5#WordDocument5XSummaryInformation(GDocumentSummaryInformation8OCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q