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

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
KNOX 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 13,800
____ 13,801 - 22,950
____ 22,951-- 36,700
____ Above 36,701
____ 26,201 – 41,950
2
____ Below 16,910
____ 16,911 - 26,200
____ Above 41,951
3
____ Below 21,330
____ 21,331 - 29,500
____ 29,501 - 47,200
____ Above 47,201
4
____ Below 25,750
____ 25,751 - 32,750
____ 32,751 - 52,400
____ Above 52,401
5
____ Below 30,170
____ 30,171- 35,400
____ 35,401 - 56,500
____ Above 56,501
6
____ Below 34,590
____ 34,591 - 38,000
____ 38,001 - 60,800
____ Above 60,801
7
____ Below 39,010
____ 39,011 - 40,650
____ 40,651 - 65,000
____ Above 65,001
8
____ Below 43,250*
____ Below 43,250
____ 43,251 - 69,200
____ Above 69,201
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 4/2019
Effective 4/1/2019
TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
KNOX 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 13,800
____ 13,801 - 22,950
____ 22,951-- 36,700
____ Above 36,701
____ 26,201 – 41,950
2
____ Below 16,910
____ 16,911 - 26,200
____ Above 41,951
3
____ Below 21,330
____ 21,331 - 29,500
____ 29,501 - 47,200
____ Above 47,201
4
____ Below 25,750
____ 25,751 - 32,750
____ 32,751 - 52,400
____ Above 52,401
5
____ Below 30,170
____ 30,171- 35,400
____ 35,401 - 56,500
____ Above 56,501
6
____ Below 34,590
____ 34,591 - 38,000
____ 38,001 - 60,800
____ Above 60,801
7
____ Below 39,010
____ 39,011 - 40,650
____ 40,651 - 65,000
____ Above 65,001
8
____ Below 43,250*
____ Below 43,250
____ 43,251 - 69,200
____ Above 69,201
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 4/2019
Effective 4/1/2019