Bradford City Water Authority
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Survey Information
THIS INFORMATION IS STRICTLY CONFIDENTIAL AND WILL BE USED ONLY
TO DETERMINE IF YOUR COMMUNITY IS ELIGIBLE FOR GRANT MONEY

TOTAL HOUSEHOLD INCOME - PLEASE CHECK BELOW
       (For Information on Income, See Bottom)

2016 COMMUNITY DEVELOPMENT BLOCK GRANT FEDERAL INCOME LIMITS:

_____  Up to 12,100          _____  Up to 49,700         _____  Up to 32,200          _____  Up to 53,400         _____  Up to 36,800

_____  Up to 57,050       _____  Up to 41,400          _____  Up to 60,750         _____  Up to 46,000         _____  Over 60,750

_______ Total Number of Persons in Family/Household

SOURCE OF INCOME - PLEASE CHECK BELOW

_____ Social Security _____ Employed _____ Pension
_____Child Support _____ Public Assistance _____ Unemployment

MARITAL STATUS:    _____Married     _____Single     _____Widowed     _____Single Parent

FAMILY MINORITY STATUS:   ______White  _____Black  _____American Indian  _____Alaskan Native  _____Asian  _____Hispanic

Is Head of Household Female?      _____YES        _____   NO

Is Head of Household Permanently Disabled?      _____   YES        _____   NO

Do you own your Home?      _____YES        _____   NO

   If NO, Name of Owner/Landlord:____________________________________

YOUR NAME AND ADDRESS: TELEPHONE NUMBER:
____________________________________________ ____________________________________________
____________________________________________
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IMPORTANT:  Please provide all information requested.  Thank You. Any false statements made knowingly and willfully may subject the signer to penalties under Section 1001 and 1010 of Title 18 of the U.S. Code.

________________________________________ ______________ ________________________________________
SIGNATURE OF FAMILY MEMBER DATE INTERVIEWER


ANNUAL INCOME INCLUDES:

1.  Gross wages before deductions of all adult members of the households.

2.  The Net income from operation of a business or profession or from rental of real or personal property.

3.  Interest and dividends.

4.  Social Security and pensions.

5.  Unemployment Compensation, Disability Compensation, Workmen's Compensation.

6.  Public Assistance.

7.  Alimony and child support.

ANNUAL INCOME DOES NOT INCLUDE:

1.   Income from dependent minors under age 18.  Heads of households and spouses may never be considered minors.

2.   Income of full-time students age 18 or older, who are not heads of households or spouses.

3.  One-time additions to family assets such as inheritances, capital gains, settlement for personal or property losses.