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

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
PENOBSCOT COUNTY
(Select portions of Penobscot 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.
Alton, Argyle, Bradford, Bradley, Burlington, Carmel,
Carroll plantation, Charleston, Chester, Clifton, Corinna,
FAMILY SIZE
FAMILY INCOME (Please Check one)
Corinth, Dexter, Dixmont, Drew plantation, East Central
(Circle One)
Penobscot UT, East Millinocket, Edinburg, Enfield,
30%
50%
80%
Above 80%
Etna, Exeter, Garland, Greenbush , Howland, Hudson,
___ 13,651 – 22,700
____22,701 – 36,300
1
____ Below 13,650
____ Above 36,301
Kingman UT, Lagrange, Lakeville, Lee, Levant, Lincoln,
2
____ Below 16,910
___ 16,911 - 25,950
____ 25,951 - 41,500
____ Above 41,501
Lowell, Mattawamkeag, Maxfield, Medway, Millinocket,
3
____ Below 21,330
___ 21,331 - 29,200
____ 29,201 - 46,700
____ Above 46,701
Mount Chase, Newburgh, Newport, North Penobscot
___ 25,751 – 32,400
____ 32,401 – 51,850
4
____ Below 25,750
____ Above 51,851
___ 30,171 – 35,000
____ 35,001 – 56,000
UT, Passadumkeag, Patten, Plymouth, Prentiss UT,
5
____ Below 30,170
____ Above 56,001
____ 37,601 – 60,150
6
____ Below 34,590
___ 34,591 - 37,600
____ Above 60,151
Seboeis plantation, Springfield, Stacyville, Stetson,
____ 40,201 – 64,300
7
____ Below 39,010
__ 39,011 - 40,200
____ Above 64,301
Twombly UT, Webster plantation, Whitney UT, Winn,
8
____ Below 42,800*
___ Below 42,800
____ 42,801 - 68,450
____ Above 68,451
Woodville
*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 ___
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
PENOBSCOT COUNTY
(Select portions of Penobscot 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.
Alton, Argyle, Bradford, Bradley, Burlington, Carmel,
Carroll plantation, Charleston, Chester, Clifton, Corinna,
FAMILY SIZE
FAMILY INCOME (Please Check one)
Corinth, Dexter, Dixmont, Drew plantation, East Central
(Circle One)
Penobscot UT, East Millinocket, Edinburg, Enfield,
30%
50%
80%
Above 80%
Etna, Exeter, Garland, Greenbush , Howland, Hudson,
___ 13,651 – 22,700
____22,701 – 36,300
1
____ Below 13,650
____ Above 36,301
Kingman UT, Lagrange, Lakeville, Lee, Levant, Lincoln,
2
____ Below 16,910
___ 16,911 - 25,950
____ 25,951 - 41,500
____ Above 41,501
Lowell, Mattawamkeag, Maxfield, Medway, Millinocket,
3
____ Below 21,330
___ 21,331 - 29,200
____ 29,201 - 46,700
____ Above 46,701
Mount Chase, Newburgh, Newport, North Penobscot
___ 25,751 – 32,400
____ 32,401 – 51,850
4
____ Below 25,750
____ Above 51,851
___ 30,171 – 35,000
____ 35,001 – 56,000
UT, Passadumkeag, Patten, Plymouth, Prentiss UT,
5
____ Below 30,170
____ Above 56,001
____ 37,601 – 60,150
6
____ Below 34,590
___ 34,591 - 37,600
____ Above 60,151
Seboeis plantation, Springfield, Stacyville, Stetson,
____ 40,201 – 64,300
7
____ Below 39,010
__ 39,011 - 40,200
____ Above 64,301
Twombly UT, Webster plantation, Whitney UT, Winn,
8
____ Below 42,800*
___ Below 42,800
____ 42,801 - 68,450
____ Above 68,451
Woodville
*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 ___
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