ࡱ> 352] 0bjbj\\ 0"6i6i ALL8+$OCpkkkkkFFF$idFFFFFkkFRkkFk =c0C"FFFFFFFFFFCFFFFFFFFFFFFFLY : TOWN/CITY OF BENEFIT DATA INFORMATION SHEET SAGADAHOC 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. 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, annual income and makeup *In determining total family income use your total gross income for the 12 month period prior to completing this form.* FAMILY SIZE INCOME 1 $34,100 Above Below 2 38,950 Above Below 3 43,800 Above Below 4 48,650 Above Below 5 52,550 Above Below 6 56,450 Above Below 7 60,350 Above Below 8 64,250 Above Below BENEFICIARY INFORMATION: Family Race: Indicate by putting a number on the appropriate line White Black/African American Asian American Indian/Alaskan Native ____ Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____ Asian & White ____ Black/African American & White ____ American Indian/Alaskan Native & Black/African American ___ Family Make-up: Enter number of elderly or severely disabled family members and indicate with an X if a female head of household is present Number of Elderly: Number of Severely Disabled: Female Head of Household: Yes _____ No _____ ============================================================================== TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI NON LMI Signature of authorized official Date     Revised 4/2024 Effective 4/1/2024 12CHpq y z 8 . ˺˺˺˺˺˺˺˺ˬqˁh_0JCJOJQJ^JaJhAOx0JCJOJQJ^JaJhE0JCJOJQJ^JaJh5#>*OJQJ^Jh5#5>*OJQJ\^J!h5#0J>*CJOJQJ^JaJh5#0JCJOJQJ^JaJ$h5#0J5>*CJOJQJ^JaJ!h5#0J5CJOJQJ^JaJ,2Cz 8 .  A o '(`$a$   " # $ % & . 7 ? A N P Q R S T \ e m o | ~  ппЯЯппЯЯппЯЯппЯЯппЯЯппЯЯпh_0JCJOJQJ^JaJhAOx0JCJOJQJ^JaJ!h5#0J>*CJOJQJ^JaJh5#0JCJOJQJ^JaJh10JCJOJQJ^JaJh#0JCJOJQJ^JaJ>    %'(@AMJ TUiuvLT^`aimwz|~Ͽ߬!h5#0J5CJOJQJ^JaJ$h5#0J5>*CJOJQJ^JaJh10JCJOJQJ^JaJhAOx0JCJOJQJ^JaJ!h5#0J>*CJOJQJ^JaJh5#0JCJOJQJ^JaJ=(AJTUv#gdc-R$a$#+,-./0ƸƪƜƘh5#h_CJOJQJ^JaJhvCJOJQJ^JaJhCJOJQJ^JaJhc-RCJOJQJ^JaJhfojhfoUh5#CJOJQJ^JaJ!h5#0J>*CJOJQJ^JaJ#+,-./0$a$gdc-R. 00/ =!"#h$% 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*CJOJQJkH44 Header  !4 @"4 Footer  !./1. c-R 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 0 0" @@@C 0 (#0 8@0(  B S  ?  . 1 "&~LS . 1 3333 "#&NT| ( + , . 1  "#&NPQT|~  + . 1 &~-"d ECU)=4*Qc-RYXCh(jluenfompDtAOxbv7^gm]|Cm|5#1_#8# @   0 @UnknownG.[x Times New Roman5Symbol3. .[x ArialC. Aptos Display3. AptosA$BCambria Math"UŇk'&Z {s{s!20 3@P?E2!xxzyLL  TOWN/CITY OFDECD Bolduc, Susan Oh+'0  0 < H T`hpxTOWN/CITY OFDECD Normal.dotmBolduc, Susan3Microsoft Office Word@vA@'X@F풓@,c{s ՜.+,0 hp  decd   TOWN/CITY OF Title  !#$%&'()+,-./014Root Entry FBc61TableWordDocument0"SummaryInformation("DocumentSummaryInformation8*CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q