ࡱ> 574] bjbj\\ $6i6iQ @LL4h{,p$?!d    R  NQe\0!!!>,$,    !LY : TOWN/CITY OF BENEFIT DATA INFORMATION SHEET YORK COUNTY/York/Kittery (Select portions of York County, see below) 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 $43,950 Above Below 2 50,200 Above Below 3 56,500 Above Below 4 62,750 Above Below 5 67,800 Above Below 6 72,800 Above Below 7 77,850 Above Below 8 82,850 Above Below Berwick , Eliot , Kittery , South Berwick ,York BENEFICIARY INFORMATION: Family Race: Indicate by putting a number on the appropriate line White Black/African American Asian American Indian/Alaskan Native _____ Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____ Asian & White ____ Black/African American & White ____ American Indian/Alaskan Native & Black/African American ___ Family Make-up: Enter number of elderly or severely disabled family members and indicate with an X if a female head of household is present Number of Elderly: Number of Severely Disabled: Female Head of Household: Yes _____ No _____ ============================================================================== TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI NON LMI Signature of authorized official Date     Revised 4/2024 Effective 4/1/2024 12Kw| l b ˽ˬˬˬˬˬˬˬˬ˚ˬˊzh[DN0JCJOJQJ^JaJh;m0JCJOJQJ^JaJ#hee5>*CJOJQJ\^JaJ!hee0J>*CJOJQJ^JaJhee0JCJOJQJ^Jhee0JCJOJQJ^JaJ$hee0J5>*CJOJQJ^JaJ!hee0J5CJOJQJ^JaJ.2Kw l b  I w 0^0`$a$       ( * + , - . 6 ? G I V X Y [ \ d m u w ࿯ϯϯhj00JCJOJQJ^JaJhj ?0JCJOJQJ^JaJh 0JCJOJQJ^JaJhV0JCJOJQJ^JaJh;m0JCJOJQJ^JaJ!hee0J>*CJOJQJ^JaJhee0JCJOJQJ^JaJh 0JCJOJQJ^JaJ/  %-/;>?ABJS[]^_`!(0UV~~~$hee0J5>*CJOJQJ^JaJheeCJOJQJ^JaJhV0JCJOJQJ^JaJ!hee0J>*CJOJQJ^JaJhee0JCJOJQJ^JaJhj00JCJOJQJ^JaJh;m0JCJOJQJ^JaJh|W0JCJOJQJ^JaJ1 /]^_`V(+20^0V()*+:A2APQRSTUVWXYZ[\]e𜔐hVCJOJQJ^JaJhYjhYUheeCJOJQJ^JaJ!hV0J>*CJOJQJ^JaJ!hee0J5CJOJQJ^JaJ$hee0J5>*CJOJQJ^JaJ!hee0J>*CJOJQJ^JaJhee0JCJOJQJ^JaJ0QSTVWYZ\]gdVefijk}heeCJOJQJ^JaJhYheeh CJOJQJ^JaJh[DNCJOJQJ^JaJhVCJOJQJ^JaJh CJOJQJ^JaJ4 00:pM (/ =!"#h$% J 00:pM (/ =!"#h$%h P0  . 00/ =!"#h$% x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH 8`8 Normal_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 8O8 Default TextCJHoH InitialStyle@B*CJOJQJkH44 Header  !4 @"4 Footer  !./1. V Footer CharPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$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$06$0$ ???????????????B Ve   8@0(  B S  ?aaaar y 9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity <BQ S T V W Y Z \ ] PV/\`iQ S T V W Y Z \ ] 33333(.V\   ;B` P Q Q S T T V W Y Z \ ] (.V\   ;B P Q Q S T T V W Y Z \ ] 7z u ^"e&M (A}3a4gX5sx>j ?.?%^CkM[DN;mVYj0|WVMl  p02 &,eeYZeQ S @AAA @UnknownG.[x Times New Roman5Symbol3. .[x ArialC. Aptos Display3. AptosA$BCambria Math"Ňk'&Z!20L L 3@P?Z2!xxx.&  TOWN/CITY OFDECD Bolduc, Susan Oh+'0  0 < H T`hpxTOWN/CITY OFDECD Normal.dotmBolduc, Susan3Microsoft Office Word@@'X@@ܙ@#e ՜.+,0 hp  decdL   TOWN/CITY OF Title  !"#%&'()*+-./01236Root Entry FEUe81Table!WordDocument$SummaryInformation($DocumentSummaryInformation8,CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q