"Benefit Data Information Sheet" - Cumberland 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 Cumberland County.

Form Details:

  • Released on April 1, 2019;
  • 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" - Cumberland County, Maine

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
CUMBERLAND COUNTY
(Select portions of Cumberland County, see list of communities below)
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)
Baldwin town, Bridgton town, Brunswick town,
(Circle One)
Harpswell town, Harrison town, Naples town, New
30%
50%
80%
Above 80%
Gloucester town, Pownal town, Sebago town
___ 15,551 – 25,900
1
____ Below 15,550
____ 25,901 - 41,450
____ Above 41,451
___ 17,801 – 29,600
2
____ Below 17,800
____ 29,601 - 47,400
____ Above 47,401
___ 21,331 – 33,300
____ 33,301 – 53,300
3
____ Below 21,330
____ Above 53,301
___ 25,751 – 37,000
4
____ Below 25,750
____ 37,001 - 59,200
____ Above 59,201
____ 40,001 – 63,950
5
____ Below 30,170
___ 30,171 - 40,000
____ Above 63,951
6
____ Below 34,590
___ 34,591 - 42,950
____ 42,951 - 68,700
____ Above 68,701
___ 39,011 – 45,900
____ 45,901 – 73,450
7
____ Below 39,010
____ Above 73,451
___ 43,431 – 48,480
____ 48,481 – 78,150
8
____ Below 43,430
____ Above 78,151
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 ___
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 4/2019
Effective 4/1/2019
TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
CUMBERLAND COUNTY
(Select portions of Cumberland County, see list of communities below)
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)
Baldwin town, Bridgton town, Brunswick town,
(Circle One)
Harpswell town, Harrison town, Naples town, New
30%
50%
80%
Above 80%
Gloucester town, Pownal town, Sebago town
___ 15,551 – 25,900
1
____ Below 15,550
____ 25,901 - 41,450
____ Above 41,451
___ 17,801 – 29,600
2
____ Below 17,800
____ 29,601 - 47,400
____ Above 47,401
___ 21,331 – 33,300
____ 33,301 – 53,300
3
____ Below 21,330
____ Above 53,301
___ 25,751 – 37,000
4
____ Below 25,750
____ 37,001 - 59,200
____ Above 59,201
____ 40,001 – 63,950
5
____ Below 30,170
___ 30,171 - 40,000
____ Above 63,951
6
____ Below 34,590
___ 34,591 - 42,950
____ 42,951 - 68,700
____ Above 68,701
___ 39,011 – 45,900
____ 45,901 – 73,450
7
____ Below 39,010
____ Above 73,451
___ 43,431 – 48,480
____ 48,481 – 78,150
8
____ Below 43,430
____ Above 78,151
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 ___
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 4/2019
Effective 4/1/2019