ࡱ> 473] ubjbj\\ 0"6i6i) KLL8+$OpkkkkkFFF$d,FFFFF,kkAJJJFRkkJFJJJkZZJW0J  JJ ^FFJFFFFF,,0FFFFFFF FFFFFFFFFLY : TOWN/CITY OF BENEFIT DATA INFORMATION SHEET FRANKLIN COUNTY Date: CDBG PROGRAM TYPE The Town/City of is currently preparing an application for Community Development Block Grant (CDBG) funds from the State of fb88, Department of Economic and Community Development. The proposed activities are to: For the proposed activities, the CDBG program requires proof of providing benefit to low and moderate-income persons. Therefore, the community is surveying the potential beneficiaries to ensure compliance with the regulations of the CDBG Program. You may be asked to provide additional in-depth income information. Your response to the following questions is critical in finalizing the application process. All responses will be kept confidential and used solely for securing CDBG grant funds. ============================================================================== Name (optional): Survey # Address: Please place an "X" in the appropriate spaces pertaining to your family's size and annual income *In determining total family income use your total gross income for the 12 month period prior to completing this form.* FAMILY SIZE INCOME 1 $28,850 Above Below 2 33,000 Above Below 3 37,100 Above Below 4 41,200 Above Below 5 44,500 Above Below 6 47,800 Above Below 7 51,100 Above Below 8 54,400 Above Below BENEFICIARY INFORMATION: Family Race: Indicate by putting a number on the appropriate line White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____ Asian & White ____ Black/African American & White ____ American Indian/Alaskan Native & Black/African American ___ Family Make-up: Enter number of elderly or severely disabled family members and indicate with an X if a female head of household is present Number of Elderly: Number of Severely Disabled: Female Head of Household: Yes ____ No _____ ============================================================================== TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI NON LMI Signature of authorized official Date     Revised 4/2024 Effective 4/1//2024 12BGop x y |   k        $ ˺˺˺˺˺˺˺˺˨ˉˉy˺hW70JCJOJQJ^JaJh g0JCJOJQJ^JaJhO>*CJOJQJ^JaJ#hO5>*CJOJQJ\^JaJ!hO0J>*CJOJQJ^JaJhO0JCJOJQJ^JaJ$hO0J5>*CJOJQJ^JaJ!hO0J5CJOJQJ^JaJ/2By |  k ( V <jk`$a$$ % & ' ( 5 7 8 : C L T V c e f h q z   )2:<IKLMήΞΞh@0JCJOJQJ^JaJhW70JCJOJQJ^JaJha0JCJOJQJ^JaJh g0JCJOJQJ^JaJhO0JCJOJQJ^JaJ!hO0J>*CJOJQJ^JaJ;MNW`hjk$%'0M [()*+,-.ࣟhyfjhyfU!hO0J5CJOJQJ^JaJ$hO0J5>*CJOJQJ^JaJ!hO0J>*CJOJQJ^JaJhO0JCJOJQJ^JaJhVA0JCJOJQJ^JaJ>k0 [)+,./124567./0123456789:;CDGHI[_bcdmnopqrstu´ަ´ޟhO0JCJOJQJ^JaJhO hahOh"CJOJQJ^JaJh@CJOJQJ^JaJhVACJOJQJ^JaJh;aCJOJQJ^JaJhaCJOJQJ^JaJhA(h@jhyfUhyf 789:;mnopqrstugda . 00/ =!"#h$% x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH 8`8 Normal_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 8O8 Default TextCJHoH InitialStyle@B*CJOJQJkH4@4 Header  !4 @"4 Footer  !./1. a Footer CharPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$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 u 0" FHJM$ M.u k7u 8@0(  B S  ?IO) + , . / 1 2 4 5 s v <i  ) + , . / 1 2 4 5 s v 33335:ch <INk ( ) ) + , , . / 1 2 4 5 m o s v  578:cefh IKLN ( ) ) + , , . / 1 2 4 5 m o s v 1&;aN$}d&A( ,5V-O05?VAz}T _eyf gal 4uyxc|<7Bu! @W7aoOYF") + @MMMu @UnknownG.[x Times New Roman5Symbol3. .[x ArialC. Aptos Display3. AptosA$BCambria Math" G[k'6f!20$ $ 3@P?YF2!xxr  TOWN/CITY OFDECD Bolduc, Susan Oh+'0  0 < H T`hpxTOWN/CITY OFDECD Normal.dotmBolduc, Susan4Microsoft Office Word@[@?^^@n^:@Z ՜.+,0 hp  decd$   TOWN/CITY OF Title  !"$%&'()*,-./012569Root Entry Fu]Z8@1Table WordDocument 0"SummaryInformation(#DocumentSummaryInformation8+MsoDataStoreZZZZ2HPGWTKNN4A==2ZZZZItem PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q