ࡱ> VXU] bjbj\\ 5T6i6i @T T 83T{+++++$!!  ++5F+++PN[ L^K0{s"$s"&s"  *{s"T Y : TOWN/CITY OF __________________ BENEFIT DATA INFORMATION SHEET YORK COUNTY (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 20,550___ 20,551 - 34,300____ 34,301 54,850____ Above 54,8512____ Below 23,500___ 23,501 39,200____ 39,201 - 62,650____ Above 62,6513____ Below 26,450___ 26,451 44,100____ 44,101 70,500____ Above 70,5014____ Below 31,200___ 31,201 48,950____ 48,951 78,300____ Above 78,3015____ Below 36,580___ 36,581 52,900____ 52,901 84,600____ Above 84,6016____ Below 41,960___ 41,961 56,800____ 56,801 90,850____ Above 90,8517____ Below 47,340___ 47,341 60,700____ 60,701 97,100____ Above 97,1018____ Below 52,720___ 52,721 64,650__ 64,651 103,400 __ Above 103,401 Acton, Alfred, Arundel, Biddeford, Cornish, Dayton, Kennebunk, Kennebunkport, Lebanon, Limerick, Lyman, Newfield, North Berwick, Ogunquit, Parsonsfield, Saco, Sanford, Shapleigh, Waterboro, Wells 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 =T ???B ]+ !$'(2 J _ :O*-{  "#%&)8@0(  B S  ?  3335#%&(tuvx 35#%&(tuvx 1tg*,+)fwl 8; =H \y/i3}4d;Ia<VQ4rU8\rdunx?r~BIkT;9aD$srJ {,W/B[\t!aOk~L*gsw-] @@UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"hSŧSŧ3CU'  ! x20 3Q@P ?T2!xx TOWN/CITY OF __________________ Smith, Andrea Bolduc, Susan Oh+'0 ( H T ` lx TOWN/CITY OF __________________Smith, Andrea Normal.dotmBolduc, Susan2Microsoft Office Word@0@rTE@ @   ՜.+,0 hp  State of fb88   TOWN/CITY OF __________________ Title  !"#$%&'()*,-./012456789:;<=>?@ABCDFGHIJKLNOPQRSTWRoot Entry F_\ YData +1Table3s"WordDocument5TSummaryInformation(EDocumentSummaryInformation8MCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q