Effective 03/29/07
BENEFIT DATA INFORMATION SHEET
PORTLAND HMFA, FY2007
Date: CDBG PROGRAM SURVEY #
Name:_________________________________________
Dear Resident,
To qualify for a CDBG funded loan/grant from the City of South Portland; the Community
Development Program needs information on the family size, annual income and makeup of all residents
who are applying for Community Development funds.
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Please place an "X" in the appropriate spaces pertaining to your family's size, annual income and makeup
and sign where requested.
FAMILY SIZE INCOME
1 $38,200 Above Below
2 $43,650 Above Below
3 $49,100 Above Below
4 $54,550 Above Below
5 $58,900 Above Below
6 $63,300 Above Below
7 $67,650 Above Below
8 $72,000 Above Below
*Read This Carefully*
In determining total family income use your Total Adjusted Gross income
for your household as reported on your most recent Federal Income Tax form.
If you use Form 1040 – use line 35
If you use Form 1040A – use line 21
If you use Form 1040EZ – use line 4
BENEFICIARY INFORMATION:
Family Race indicate by putting an "X" 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 ___ Other _____
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
Effective 03/29/07
I certify that the information on this survey form is true and complete to the best of my
knowledge and belief, and that the City of South Portland, the State of Maine and the Federal
Government are hereby authorized to verify the information contained herein.
Signature
==========================================================================
TO BE FILLED OUT BY INDEPENDENT VERIFIER: LMI NON LMI
Signature of authorized official Date

The deadline to apply for assistance for rec camp &middle school camp is Monday, April 14, 2008. I am attaching the two forms that parent must complete. We must have their 2007 tax return.

South Portland Parks and Recreation
FINANCIAL ASSISTANCE APPLICATION
Financial assistance is provided to South Portland residents only. This form must be completed and returned to the South
Portland Community Center accompanied by each adult’s most recent State or Federal income tax return. Individuals
must complete a new application for each calendar year.
Name of the adult requesting assistance_______________________________________________________________
Address ________________________________________________________________________________________
Street City/State/Zip Mailing address if different
Home phone ________________________Work phone__________________
Please list below the names of all individuals who reside at the above address. You must provide the social security
number for each adult and the date of birth for each child.
1.________________________________________ 2.____________________________________________
3.________________________________________ 4.____________________________________________
5._______________________________________ 6.____________________________________________
7.________________________________________ 8.____________________________________________
PLEASE INDICATE BELOW WHO YOU ARE REQUESTING ASSISTANCE FOR AND WHAT PROGRAM
Name_________________________Age ____Grade____ School ____________Program__________________________
(if under age of 18)
Name ________________________Age _____Grade____ School ____________Program_________________________
(if under age of 18)
Name ________________________Age _____Grade____ School ____________Program_________________________
(if under age of 18)
Name ________________________Age _____Grade____ School ____________Program_________________________
(if under age of 18)
If you are requesting assistance for summer rec camp or tot lot please indicate how many weeks of camp you would like
your child to attend.
LIST ALL OTHER HOUSEHOLD INCOME AND PROVIDE DOCUMENTS TO VERIFY. Please tell us the
amount that you receive each month.
Social Security $______________ Child Support $ _____________ Welfare $ ________________
Alimony $ __________________ Food Stamps $______________ Pension $ ________________
Family Support $ ____________ Other funding $_____________ Other income $____________
CIRCLE ALL BENEFITS WHICH YOU RECEIVE
Reduced School Lunch Free School Lunch Subsidized Housing Medicaid
FINANCIAL INFORMATION THAT MUST BE PROVIDED
You must list each adult who lives at this residence and provide the requested information. Failure to include all
information will result in your application being denied.
1._____________________ _____________________ _________________ __________ _____________
Name of adult Name of Employer Employer’s Phone Hourly Wage Weekly Net Pay
2. ______________________ ______________________ __________________ ___________ ______________
Name of adult Name of Employer Employer’s Phone Hourly Wage Weekly Net Pay
3. _____________________ ______________________ __________________ __________ ______________
Name of adult Name of Employer Employer’s Phone Hourly Wage Weekly Net Pay
PLEASE USE THIS SPACE TO LIST ALL HOUSEHOLD EXPENSES
AND HOW MUCH YOU PAY EACH MONTH FOR EACH EXPENSE
____________________________________________ __________________________________________
____________________________________________ __________________________________________
____________________________________________ __________________________________________
____________________________________________ __________________________________________
____________________________________________ __________________________________________
____________________________________________ __________________________________________
Signature of adult requesting assistance___________________________________________Today’s Date______________
I certify that all of the information provided is true and that I am responsible to notify South Portland Parks & Recreation of any
change of family or financial status immediately should they occur. I understand that this completed form will be used solely for the
purpose of determining financial assistance. I authorize a representative from the South Portland Parks & Recreation Department to
contact city/state welfare and other officials to determine the accuracy of my financial situation.
RETURN THIS COMPLETED FORM AND YOUR MOST RECENT STATE OR FEDERAL INCOME TAX RETURN TO:
South Portland Recreation
21 Nelson Road
So. Portland, ME. 04106
207-767-7650
PLEASE MAKE NOTE OF OUR GUIDELINES
1. We do not provide assistance for programs that have a fee of $50.00 or less. We will provide a payment plan if
requested.
2. Financial assistance must be requested prior to the start of the program.
3. We cannot provide financial assistance if you have an outstanding balance for recreational programs.
4. If you want to request financial assistance at the time that you register for a program you will need to complete
the registration form and make a minimum deposit to hold your spot in the class. If financial assistance is
provided and a refund is necessary, we will gladly process one for you.
5. We will only process requests for financial assistance for current programs. Vacation camps will be processed
one camp at a time.
6. You will be notified in writing about the amount of assistance that is available for you.
(revised 10/8/02)

Our lottery is being held April 13 – 17, 2008 this year. Parents need to get a financial assistance forms and registration forms at the community center.

We anticipate a larger than usual number of financial assistance requests this year. The requests will be processed as we receive them.