ࡱ> =?<] bjbj\\ 126i6iL @uuuuu8d%99999$o!uuu99Fu9u99Zv~0 "l " "u<r "Y ;: TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET SAGADAHOC 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 20,450 ____ 20,451 - 34,100 ____ 34,101 - 54,500 ____ Above 54,501 2 ____ Below 23,400 ____ 23,401 - 38,950 ____ 38,951 - 62,300 ____ Above 62,301 3 ____ Below 26,300 ____ 26,301 - 43,800 ____ 43,801 - 70,100 ____ Above 70,101 4 ____ Below 31,200 ____ 31,201 - 48,650 ____ 48,651 - 77,850 ____ Above 77,851 5 ____ Below 36,580 ____ 36,581 - 52,550 ____ 52,551 - 84,100 ____ Above 84,10]1 6 ____ Below 41,960 ____ 41,961 - 56,450 ____ 56,451 90,350 ____ Above 90,351 7 ____ Below 47,340 ____ 47,341 - 60,350 ____ 60,351 - 96,550 ____ Above 96,551 8 ____ Below 52,720 ____ 52,721 64,250 ____ 64,251 - 102,800 ____ Above 102,801 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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" #$% 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 FontViV  Table Normal :V 44 la (k (No List *W * Strong5\@@  Balloon Text CJ^JaJ@O@ Default Text OJQJaJHoH InitialStyle@B*CJOJQJkH424 Header  !4 @B4 Footer  !>/Q> 4V 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 02 ???B mK R 8@0(  B S  ?L N O Q R T U W X 9 = L N O Q R T U W X 3333tuvw')*+!#$%689:|}~K K L L N O O Q R T U W X tuvw')*+!#$%689:|}~K K L L N O O Q R T U W X .-GLwCZ by tV;S'B,*Ih,M4? 7lD[SSU4V_aoue4)r^ExH8Rk\@W96'Nk'[|jlVq`"t _6L N @... @UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"hRŧRŧ2CU'P P ! x20F F 3Q@P ?M42!xxz TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@0@,!@`O@`OP  ՜.+,0 hp  State of fb88F   TOWN/CITY OF __________________ Title  !"#$%&'()*+-./012356789:;>Root Entry FT@1Table "WordDocument12SummaryInformation(,DocumentSummaryInformation84CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q