"Benefit Data Information Sheet" - Kennebec County, Maine

Benefit Data Information Sheet is a legal document that was released by the Maine Department of Economic & Community Development - a government authority operating within Maine. The form may be used strictly within Kennebec County.

Form Details:

  • Released on April 1, 2020;
  • The latest edition currently provided by the Maine Department of Economic & Community Development;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Maine Department of Economic & Community Development.

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Download "Benefit Data Information Sheet" - Kennebec County, Maine

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
KENNEBEC COUNTY
Date: ___________
CDBG EDP SURVEY #: ___________
The Town/City of ____________________________ has been awarded Community Development Block Grant (CDBG) funds from the State of Maine, 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.*
Please circle your family size and place a check mark on the corresponding line for the income level for your family size.
FAMILY SIZE:
FAMILY INCOME:
(Please check one)
(Please Circle one)
30%
50%
80%
Above 80%
____ 15,851 – 26,400
____ 26,401 – 42,250
1
____ Below 15,850
____ Above 42,251
____ 18,101 – 30,200
____ 30,201 – 48,250
2
____ Below 18,100
____ Above 44,751
____ 21,721 – 33,950
____ 33,951 – 54,300
3
____ Below 21,720
____ Above 54,301
____ 26,201 – 37,700
____ 37,701 – 60,300
4
____ Below 26,200
____ Above 60,301
____ 30,681 – 40,750
____ 40,751 – 65,150
5
____ Below 30,680
____ Above 65,151
____ 35,161 – 43,750
____ 43,751 – 69,950
6
____ Below 35,160
____ Above 69,951
____ 39,641 – 46,750 ____ 46,751 – 74,800 ____ Above 74,801
7
____ Below 39,640
____ 44,121 - 49,800 ____ 49,801 – 79,600
8
____ Below 44,120
____ Above 79,601
*The FY 2014 Consolidated Appropriations Act changed the definition of extremely low income. Consequently the 30% income limits may equal the 50% income limits
BENEFICIARY INFORMATION:
Family Race: Indicate by putting 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 ___ Other ___
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 ____ Before taking this job were you employed? Yes ___ No ___
I certify that the information on this survey form is true and complete to the best of my knowledge and belief, and that that Town/City of ______________,
the State of Maine, and the Federal Government are hereby authorized to verify the information contained herein.
_______________________________________________________
Signature
Date
========================================================================================== ========================================
TO BE FILLED OUT BY INDEPENDENT VERIFIER:
LMI ___
NON-LMI___
________________________________________________________________________________________
Signature of authorized official
Date
Revised 4/2020
Effective 4/1/2020
TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
KENNEBEC COUNTY
Date: ___________
CDBG EDP SURVEY #: ___________
The Town/City of ____________________________ has been awarded Community Development Block Grant (CDBG) funds from the State of Maine, 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.*
Please circle your family size and place a check mark on the corresponding line for the income level for your family size.
FAMILY SIZE:
FAMILY INCOME:
(Please check one)
(Please Circle one)
30%
50%
80%
Above 80%
____ 15,851 – 26,400
____ 26,401 – 42,250
1
____ Below 15,850
____ Above 42,251
____ 18,101 – 30,200
____ 30,201 – 48,250
2
____ Below 18,100
____ Above 44,751
____ 21,721 – 33,950
____ 33,951 – 54,300
3
____ Below 21,720
____ Above 54,301
____ 26,201 – 37,700
____ 37,701 – 60,300
4
____ Below 26,200
____ Above 60,301
____ 30,681 – 40,750
____ 40,751 – 65,150
5
____ Below 30,680
____ Above 65,151
____ 35,161 – 43,750
____ 43,751 – 69,950
6
____ Below 35,160
____ Above 69,951
____ 39,641 – 46,750 ____ 46,751 – 74,800 ____ Above 74,801
7
____ Below 39,640
____ 44,121 - 49,800 ____ 49,801 – 79,600
8
____ Below 44,120
____ Above 79,601
*The FY 2014 Consolidated Appropriations Act changed the definition of extremely low income. Consequently the 30% income limits may equal the 50% income limits
BENEFICIARY INFORMATION:
Family Race: Indicate by putting 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 ___ Other ___
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 ____ Before taking this job were you employed? Yes ___ No ___
I certify that the information on this survey form is true and complete to the best of my knowledge and belief, and that that Town/City of ______________,
the State of Maine, and the Federal Government are hereby authorized to verify the information contained herein.
_______________________________________________________
Signature
Date
========================================================================================== ========================================
TO BE FILLED OUT BY INDEPENDENT VERIFIER:
LMI ___
NON-LMI___
________________________________________________________________________________________
Signature of authorized official
Date
Revised 4/2020
Effective 4/1/2020