"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, 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" - Penobscot County, Maine

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TOWNCITY OF
BENEFIT DATA INFORMATION SHEET
PENOBSCOT COUNTY
(Select portions of Penobscot County, see list of communities below)
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.
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, annual income and makeup
*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,
FAMILY SIZE INCOME
Clifton, Corinna, Corinth , Dexter, Dixmont , Drew
plantation, East Central Penobscot UT, East
1
$37,700
Above
Below _____
Millinocket, Edinburg, Enfield , Etna , Exeter ,
2
43,100
Above
Below
Garland , Greenbush , Howland, Hudson,
3
48,500
Above
Below
Kingman UT, Lagrange, Lakeville , Lee , Levant,
4
53,850
Above
Below
Lincoln , Lowell , Mattawamkeag , Maxfield,
5
58,200
Above
Below
Medway , Millinocket , Mount Chase, Newburgh,
6
62,500
Above
Below
Newport , North Penobscot UT, Passadumkeag,
Patten , Plymouth , Prentiss UT, Seboeis
7
66,800
Above
Below
plantation, Springfield , Stacyville , Stetson ,
8
71,100
Above
Below
Twombly UT, Webster plantation, Whitney UT,
Winn, Woodville
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 4/2020
Effective 4/1/2020
TOWNCITY OF
BENEFIT DATA INFORMATION SHEET
PENOBSCOT COUNTY
(Select portions of Penobscot County, see list of communities below)
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.
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, annual income and makeup
*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,
FAMILY SIZE INCOME
Clifton, Corinna, Corinth , Dexter, Dixmont , Drew
plantation, East Central Penobscot UT, East
1
$37,700
Above
Below _____
Millinocket, Edinburg, Enfield , Etna , Exeter ,
2
43,100
Above
Below
Garland , Greenbush , Howland, Hudson,
3
48,500
Above
Below
Kingman UT, Lagrange, Lakeville , Lee , Levant,
4
53,850
Above
Below
Lincoln , Lowell , Mattawamkeag , Maxfield,
5
58,200
Above
Below
Medway , Millinocket , Mount Chase, Newburgh,
6
62,500
Above
Below
Newport , North Penobscot UT, Passadumkeag,
Patten , Plymouth , Prentiss UT, Seboeis
7
66,800
Above
Below
plantation, Springfield , Stacyville , Stetson ,
8
71,100
Above
Below
Twombly UT, Webster plantation, Whitney UT,
Winn, Woodville
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 4/2020
Effective 4/1/2020