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General Survey Form 2

This is a grant survey form.

General Survey Form 2
General Survey Form 2
GRANT SURVEY FORM
(Read Instructions on the Reverse Side Before Completing)
NOTICE: This form should be used for actual survey collection.
Resident Providing Information:__________________________________________________________
(Please Print)
Street Address:_______________________________________________________________________
Do You Own or Rent This House _____ OWN _____ RENT
The Following Information is Needed to Submit an Application for a Grant:
1. Determine the correct number of person(s) in the household and circle that number in the
appropriate box below.
2. Look at the amount of money listed in the block that is circled. Is the total household income
above or below that amount of money
3. Place a check after either “Above” or “Below” to match the appropriate answer in Question 2.
1
2
3
4
5
6
7
8
Person
Persons
Persons
Persons
Persons
Persons
Persons
Persons
$
$
$
$
$
$
$
$
Above ( )
Above ( )
Above ( )
Above ( )
Above ( )
Above ( )
Above ( )
Above ( )
Below ( )
Below ( )
Below ( )
Below ( )
Below ( )
Below ( )
Below ( )
Below ( )
The income limited listed in the boxes above are from the county of:______________________________
DATA REPORTING INFORMATION:
Complete the following table regarding the number of persons who will directly benefit from this project:
IDIS Numbers
Total
Hispanic
IDIS Numbers
Total
11. White
20. Other Multi-Racial
12. Black/African American
21. Female Heads of
Household
13. Asian
22. Number of Minorities
14. American Indian/
Alaskan Native
23. Number of Elderly (+62)
15. Native Hawaiian/Other
Pacific Islander
24. Number of Handicapped
16. American Indian/
Alaskan Native and White
25. Number of Children 18 or
Younger
17. Asian and White
18. Black/African American
and White
19. American Indian/Alaskan
Native and Black/African
American
Signature of Person Completing this Form:_________________________________________________
Date this Form Completed:______________________________________________________________
TO BE COMPLETED BY RESIDENT PROVIDING INFORMATION
Signature or Initials of Resident
Providing Information:_________________________________________________________________
Home Telephone Number:_____________________________________________________________
_____ Check box if answer to Question 3 is “Below” Map House ID Number____________________
General Survey Form 2
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