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

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TOWN/CITY OF __________________
BENEFIT DATA INFORMATION SHEET
SAGADAHOC 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 16,500
____ 16,501 - 27,500
____ 27,501 - 44,000
____ Above 44,401
2
____ Below 18,850
____ 18,851 - 31,400
____ 31,401 - 50,250
____ Above 50,251
3
____ Below 21,720
____ 21,721 - 35,350
____ 35,351 - 56,550
____ Above 56,551
4
____ Below 26,200
____ 26,201 - 39,250
____ 39,251 - 62,800
____ Above 62,801
5
____ Below 30,680
____ 30,681 - 42,400
____ 42,401 - 67,850
____ Above 67,851
____ 45,551 – 72,850
6
____ Below 35,160
____ 35,161 - 45,550
____ Above 72,851
7
____ Below 39,640
____ 39,641 - 48,700
____ 48,701 - 77,900
____ Above 77,901
____ 44,121 – 51,850
8
____ Below 44,120
____ 51,851 - 82,900
____ Above 82,901
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
SAGADAHOC 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 16,500
____ 16,501 - 27,500
____ 27,501 - 44,000
____ Above 44,401
2
____ Below 18,850
____ 18,851 - 31,400
____ 31,401 - 50,250
____ Above 50,251
3
____ Below 21,720
____ 21,721 - 35,350
____ 35,351 - 56,550
____ Above 56,551
4
____ Below 26,200
____ 26,201 - 39,250
____ 39,251 - 62,800
____ Above 62,801
5
____ Below 30,680
____ 30,681 - 42,400
____ 42,401 - 67,850
____ Above 67,851
____ 45,551 – 72,850
6
____ Below 35,160
____ 35,161 - 45,550
____ Above 72,851
7
____ Below 39,640
____ 39,641 - 48,700
____ 48,701 - 77,900
____ Above 77,901
____ 44,121 – 51,850
8
____ Below 44,120
____ 51,851 - 82,900
____ Above 82,901
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