"Benefit Data Information Sheet" - Franklin 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 Franklin 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.

ADVERTISEMENT
ADVERTISEMENT

Download "Benefit Data Information Sheet" - Franklin County, Maine

147 times
Rate (4.5 / 5) 10 votes
TOWN/CITY OF
BENEFIT DATA INFORMATION SHEET
FRANKLIN COUNTY
Date:
CDBG PROGRAM TYPE
The Town/City of
is currently preparing an application for
Community Development Block Grant (CDBG) funds from the State of Maine, Department of Economic and
Community Development. The proposed activities are to:
For the proposed activities, the CDBG program requires proof of providing benefit to low and
moderate-income persons. Therefore, the community is surveying the potential beneficiaries to ensure
compliance with the regulations of the CDBG Program. You may be asked to provide additional in-depth
income information.
Your response to the following questions is critical in finalizing the application process. All responses
will be kept confidential and used solely for securing CDBG grant funds.
==============================================================================
Name (optional):
Survey #
Address:
Please place an "X" in the appropriate spaces pertaining to your family's size and annual income
*In determining total family income use your total gross income for the 12 month period prior to
completing this form.*
FAMILY SIZE INCOME
1
$36,300
Above
Below
2
41,500
Above
Below
3
46,700
Above
Below
4
51,850
Above
Below
5
56,000
Above
Below
6
60,150
Above
Below
7
64,300
Above
Below
8
68,450
Above
Below
BENEFICIARY INFORMATION:
Family Race: Indicate by putting a number on the appropriate line
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____
Asian & White ____
Black/African American & White ____
American Indian/Alaskan Native & Black/African American ___
Family Make-up: Enter number of elderly or severely disabled family members and indicate with an “X” if a
female head of household is present
Number of Elderly:
Number of Severely Disabled:
Female Head of Household: Yes ____ No _____
==============================================================================
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
FRANKLIN COUNTY
Date:
CDBG PROGRAM TYPE
The Town/City of
is currently preparing an application for
Community Development Block Grant (CDBG) funds from the State of Maine, Department of Economic and
Community Development. The proposed activities are to:
For the proposed activities, the CDBG program requires proof of providing benefit to low and
moderate-income persons. Therefore, the community is surveying the potential beneficiaries to ensure
compliance with the regulations of the CDBG Program. You may be asked to provide additional in-depth
income information.
Your response to the following questions is critical in finalizing the application process. All responses
will be kept confidential and used solely for securing CDBG grant funds.
==============================================================================
Name (optional):
Survey #
Address:
Please place an "X" in the appropriate spaces pertaining to your family's size and annual income
*In determining total family income use your total gross income for the 12 month period prior to
completing this form.*
FAMILY SIZE INCOME
1
$36,300
Above
Below
2
41,500
Above
Below
3
46,700
Above
Below
4
51,850
Above
Below
5
56,000
Above
Below
6
60,150
Above
Below
7
64,300
Above
Below
8
68,450
Above
Below
BENEFICIARY INFORMATION:
Family Race: Indicate by putting a number on the appropriate line
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____
Asian & White ____
Black/African American & White ____
American Indian/Alaskan Native & Black/African American ___
Family Make-up: Enter number of elderly or severely disabled family members and indicate with an “X” if a
female head of household is present
Number of Elderly:
Number of Severely Disabled:
Female Head of Household: Yes ____ No _____
==============================================================================
TO BE FILLED OUT BY INDEPENDENT VERIFIER:
LMI
NON LMI
Signature of authorized official
Date
Revised 4/2019
Effective 4/1/2019