ࡱ> UWT] bjbj\\ 5R6i6i{ JT T 83L+++++npppppp$K"++dddR++ndnddd+ixWXjdZ0d"N"dd&"dT"T Y : TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET YORK COUNTY/YORK/KITTERY (Select portions of York 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 26,400___ 26,401 - 43,950____ 43,951 68,500____ Above 68,5012____ Below 30,150___ 30,151 50,200____ 50,201 78,250____ Above 78,2513____ Below 33,900___ 33,901 - 56,500____ 56,501 - 88,050____ Above 88,0514____ Below 37,650___ 37,651 - 62,750____ 62,751 - 97,800____ Above 97,8015____ Below 40,700___ 40,701 - 67,800____ 67,801 - 105,650____ Above 105,6516____ Below 43,700___ 43,701 - 72,800___ 72,801 - 113,450____ Above 113,4517____ Below 47,340___ 47,341 77,850____ 77,851 - 121,300____ Above 121,3018____ Below 52,720___ 52,721 82,850____ 82,851 - 129,100____ Above 129,101 Berwick, Eliot, Kittery, South Berwick, York 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 0R EGIL + "&(? W l G\<?}  !#$%'8@0(  B S  ?{ } ~ i m { } ~ 33ABCE578:wxz z { { } ~ ~ ABCE578:wxz z { { } ~ ~ 1tg*.-G$9P!q!+;6n9UwIdR~jS T}o6rbg Uqu-206qN&r'1We KxI\o S_;KPy23y)a3{ } @::: @UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"h@k'@k'2CU'x x ! x20u u 3Q@P ?G2!xx]A^ TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@G@,!@hV@hVx  ՜.+,0 hp  State of fb88u   TOWN/CITY OF __________________ Title  !"#$%&'()+,-./013456789:;<=>?@ABCEFGHIJKMNOPQRSVRoot Entry F-yWXData *1Table2"WordDocument5RSummaryInformation(DDocumentSummaryInformation8LCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q