"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, 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" - 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 14,350
____ 14,351 - 23,900
____ 23,901-- 38,200
____ Above 38,201
____ 27,301 – 43,650
2
____ Below 17,240
____ 17,241 - 27,300
____ Above 43,651
3
____ Below 21,720
____ 21,721 - 30,700
____ 30,701 - 49,100
____ Above 49,101
4
____ Below 26,200
____ 26,201 - 34,100
____ 34,101 - 54,550
____ Above 54,551
5
____ Below 30,680
____ 30,681- 36,850
____ 36,851 - 58,950
____ Above 58,951
6
____ Below 35,160
____ 35,161 - 39,600
____ 39,601 - 63,300
____ Above 63,301
7
____ Below 39,640
____ 39,641 - 42,300
____ 42,301 - 67,650
____ Above 67,651
8
____ Below 44,120*
____ Below 45,050
____ 45,051 - 72,050
____ Above 72,051
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
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 14,350
____ 14,351 - 23,900
____ 23,901-- 38,200
____ Above 38,201
____ 27,301 – 43,650
2
____ Below 17,240
____ 17,241 - 27,300
____ Above 43,651
3
____ Below 21,720
____ 21,721 - 30,700
____ 30,701 - 49,100
____ Above 49,101
4
____ Below 26,200
____ 26,201 - 34,100
____ 34,101 - 54,550
____ Above 54,551
5
____ Below 30,680
____ 30,681- 36,850
____ 36,851 - 58,950
____ Above 58,951
6
____ Below 35,160
____ 35,161 - 39,600
____ 39,601 - 63,300
____ Above 63,301
7
____ Below 39,640
____ 39,641 - 42,300
____ 42,301 - 67,650
____ Above 67,651
8
____ Below 44,120*
____ Below 45,050
____ 45,051 - 72,050
____ Above 72,051
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