2006 LMI Sample Survey – Kansas Small Cities CDBG Program



2009 LMI Sample Survey – Kansas Small Cities CDBG Program

The Communities of Franklin and Miami Counties are conducting a survey to determine the need for improvements in public facilities and services. Some of the improvement projects may be eligible for Federal funding. Your answers will be kept confidential and a public hearing will be held regarding potential improvement projects prior to any grant applications being submitted.

1) Home Address: ____________________________________

2) How many persons live at this address? ______________________

3) How many persons are unrelated individuals (not members of family)? _________

4) How many families (persons related by birth, marriage, or adoption) live at this address? _________

How many persons are in each family?

Family 1__________ Family 2__________ Family 3___________

NOTE: If more than one family or unrelated individual lives at this address, please check the appropriate line for each family or unrelated individual.

Total Household Income

| |Below | |LMI | |Above |

|Family Size (Circle) |Income | |Income Limit | |Income |

|One Person (unrelated individuals) | | |$28,550 | | |

|Two Persons | | |$32,650 | | |

|Three Persons | | |$36,700 | | |

|Four Persons | | |$40,800 | | |

|Five Persons | | |$44,050 | | |

|Six Persons | | |$47,350 | | |

|Seven Persons | | |$50,600 | | |

|Eight Persons | | |$53,850 | | |

Household Demographic Information

Race

___White ___Black/African American ___Native Hawaiian/Other Pacific Islander

___Asian ___American Indian/Alaskan Native ___American Indian/Alaskan Native & White

___Asian & White ___Black/African American & White ___Balance/Other

___American Indian/Alaskan native & Black/African American

Ethnicity: ___Hispanic ___Non-Hispanic

Are any persons at this address

Female Head of Household Disabled1 over 65 years of age?

___ Yes ___Yes ___Yes

___ No ___ No ___No

How many? _____ How many? ______ How many? ____

1A disabled person is defined as a person who has a physical or mental impairment which substantially limits one or more of such person’s major life activities, has a record of such an impairment, or is regarded as having such an impairment.

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