CDBG BENEFICIARY SURVEY FORM

PROJECTS WITH WATER/SEWER CONNECTIONS

The City of Alabamaville has received funding from the Alabama Department of Economic and Community Affairs for a Community Development Block Grant to extend public sewer service to your neighborhood. In order to determine if each household to be connected to the sewer system as part of this project meets eligibility criteria, the following information must be obtained from all proposed beneficiaries.

Name/Address of Occupant:

HOUSEHOLD INCOME BY FAMILY SIZE

(Circle the HUD Section 8 Income Limit below which most closely corresponds to your total household income from all sources for the previous 12 months.)

HOUSEHOLD
SIZE / 1 Person / 2 Person / 3 Person / 4 Person / 5 Person / 6 Person / 7 Person / 8 Person
Very Low / $0 to / $0 to / $0 to / $0 to / $0 to / $0 to / $0 to / $0 to
Income / $______/ $______/ $______/ $______/ $______/ $______/ $______/ $______
$______/ $______/ $______/ $______/ $______/ $______/ $______/ $______
Low / to / to / to / to / to / to / to / to
Income / $______/ $______/ $______/ $______/ $______/ $______/ $______/ $______
$______/ $______/ $______/ $______/ $______/ $______/ $______/ $______
Moderate / to / to / to / to / to / to / to / to
Income / $______/ $______/ $______/ $______/ $______/ $______/ $______/ $______
High / Over / Over / Over / Over / Over / Over / Over / Over
Income / $______/ $______/ $______/ $______/ $______/ $______/ $______/ $______

CERTIFICATION: I ATTEST THAT INFORMATION STATED ABOVE IS TRUE AND ACCURATE. I UNDERSTAND THAT THE ABOVE INFORMATION IS SUBJECT TO VERIFICATION AND IF MISREPRESENTED OR INCOMPLETE, I MAY BE SUBJECT TO PENALITIES AS SPECIFIED BY THE LAW (U.S. C. Title 18, Sec. 1001).

Homeowner/Tenant: Date: