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

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
PISCATAQUIS 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.
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%
1
____ Below 14,150
____ 14,151 - 23,600
____ 23,601 - 37,700
____ Above 37,701
2
____ Below 17,240
____ 17,241 - 26,950
____ 26,951 - 43,100
____ Above 43,101
____ 30,301 – 48,500
3
____ Below 21,720
____ 21,721 - 30,300
____ Above 48,501
____ 33,651 – 53,850
4
____ Below 26,200
____ 26,201 - 33,650
____ Above 53,851
____ 30,681 – 36,350
5
____ Below 30,680
____ 36,351 - 58,200
____ Above 58,201
____ 35,161 – 39,050
6
____ Below 35,160
____ 39,051 - 62,500
____ Above 62,501
____ 39,641 – 41,750
7
____ Below 39,640
____ 41,751 - 66,800
____ Above 66,801
8
____ Below 44,120*
____ Below 44,450
____ 44,451 - 71,100
____ Above 71,101
*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
PISCATAQUIS 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.
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%
1
____ Below 14,150
____ 14,151 - 23,600
____ 23,601 - 37,700
____ Above 37,701
2
____ Below 17,240
____ 17,241 - 26,950
____ 26,951 - 43,100
____ Above 43,101
____ 30,301 – 48,500
3
____ Below 21,720
____ 21,721 - 30,300
____ Above 48,501
____ 33,651 – 53,850
4
____ Below 26,200
____ 26,201 - 33,650
____ Above 53,851
____ 30,681 – 36,350
5
____ Below 30,680
____ 36,351 - 58,200
____ Above 58,201
____ 35,161 – 39,050
6
____ Below 35,160
____ 39,051 - 62,500
____ Above 62,501
____ 39,641 – 41,750
7
____ Below 39,640
____ 41,751 - 66,800
____ Above 66,801
8
____ Below 44,120*
____ Below 44,450
____ 44,451 - 71,100
____ Above 71,101
*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