"Benefit Data Information Sheet" - Androscoggin 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 Androscoggin 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" - Androscoggin County, Maine

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
ANDROSCOGGIN COUNTY
(Uses Lewiston/Auburn MSA)
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.
securing CDBG
Your response to the following questions is critical for meeting CDBG program requirements. All responses are confidential and used solely for
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:
FAMILY INCOME:
(Please check one)
(Please Circle one)
30%
50%
80%
Above 80%
____ 24,501 – 39,150
1
____ Below 14,700
____ 14,701 - 24,500
____ Above 39,151
____ 28,001 – 44,750
2
____ Below 17,240
____ 17,241 - 28,000
____ Above 44,751
____ 31,501 – 50,350
3
____ Below 21,720
____ 21,721 - 31,500
____ Above 50,351
____ 34,951 – 55,900
4
____ Below 26,200
____ 26,201 - 34,950
____ Above 55,901
____ 37,751 – 60,400
5
____ Below 30,680
____ 30,681 - 37,750
____ Above 60,401
____ 40,551 – 64,850
6
____ Below 35,160
____ 35,161 - 40,550
____ Above 64,851
7
____ Below 39,640
____ 39,641 - 43,350
____ 43,351 - 69,350 ____ Above 69,351
8
____ Below 44,120*
____ Below 46,150*
____ 46,151 - 73,800 ____ Above 73,801
*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:
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 ___ Other ___
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? 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 the Town/City of ______________,
the State of Maine, and the Federal Government are hereby authorized to verify the information contained herein.
____________________________________________________________________________________________________________________
Signature
Printed Name
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
ANDROSCOGGIN COUNTY
(Uses Lewiston/Auburn MSA)
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.
securing CDBG
Your response to the following questions is critical for meeting CDBG program requirements. All responses are confidential and used solely for
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:
FAMILY INCOME:
(Please check one)
(Please Circle one)
30%
50%
80%
Above 80%
____ 24,501 – 39,150
1
____ Below 14,700
____ 14,701 - 24,500
____ Above 39,151
____ 28,001 – 44,750
2
____ Below 17,240
____ 17,241 - 28,000
____ Above 44,751
____ 31,501 – 50,350
3
____ Below 21,720
____ 21,721 - 31,500
____ Above 50,351
____ 34,951 – 55,900
4
____ Below 26,200
____ 26,201 - 34,950
____ Above 55,901
____ 37,751 – 60,400
5
____ Below 30,680
____ 30,681 - 37,750
____ Above 60,401
____ 40,551 – 64,850
6
____ Below 35,160
____ 35,161 - 40,550
____ Above 64,851
7
____ Below 39,640
____ 39,641 - 43,350
____ 43,351 - 69,350 ____ Above 69,351
8
____ Below 44,120*
____ Below 46,150*
____ 46,151 - 73,800 ____ Above 73,801
*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:
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 ___ Other ___
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? 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 the Town/City of ______________,
the State of Maine, and the Federal Government are hereby authorized to verify the information contained herein.
____________________________________________________________________________________________________________________
Signature
Printed Name
Date
==================================================================================================================================
TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI ___ NON-LMI___
________________________________________________________________________________________
Signature of authorized official
Date
Revised 4/2020
Effective 4/1/2020