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Respondents indicate the number of persons living in the family and match income status to the appropriate figure by family size. The form also gathers racial characteristics and head-of-household status, plus ethnicity selection. 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do the signature fields cover?","Question",{"text":109,"@type":110},"The form includes respondent signature and date, plus interviewer signature and date, and references potential penalties for knowingly false statements.","Answer","https://schema.org",{"og:url":78,"og:type":113,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":115,"canonical":78},"index,follow",{"doc_id":117,"site_id":56},306898,1791461494,{"code":4,"msg":5,"data":120},{"doc_id":117,"user_id":121,"nickname":88,"user_avatar":60,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":4},8796093062539,"SURVEY AREA &MUNICIPALITYCOUNTY  \nFor the purpose of determining eligibility for proposed community development projects to be fundedby the Pennsylvania Community Development Block Grant Program,the following information isnecessary.Indicate the number of persons living in the family,and going straight across,whether familyincome is below,between or above the listed figure for the appropriate family size.  \n\n| \\#of people  \u003Cbr>in family   | INCOME   |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| □1 Person   | Income is:   | □ below  \u003Cbr>$0   | □ between   | $0  \u003Cbr>&   |  | $0   | □ above  \u003Cbr>$0   |\n| □ 2 Person   | Income is:   | $0  \u003Cbr>□ below   | □ between   | &  \u003Cbr>$0   |  | $0   | $0  \u003Cbr>□ above   |\n| □3 Person   | Income is:   | □ below  \u003Cbr>$0   | □ between   | $0   | &   | $0   | □ above  \u003Cbr>$0   |\n| □4 Person   | Income is:   | □ below  \u003Cbr>$0   | □ between   | &  \u003Cbr>$0   |  | $0   | □ above  \u003Cbr>$0   |\n| □5 Person   | Income is:   | □ below  \u003Cbr>$0   | □ between   | $0  \u003Cbr>&   |  | $0   | □ above  \u003Cbr>$0   |\n| □6 Person   | Income is:   | $0  \u003Cbr>□ below   | □ between   | &  \u003Cbr>$0   |  | $0   | $0  \u003Cbr>□ above   |\n| □7 Person   | Income is:   | $0  \u003Cbr>□ below   | □ between   | $0  \u003Cbr>&   |  | $0   | $0  \u003Cbr>□ above   |\n| □8 Person   | Income is:   | □ below  \u003Cbr>$0   | □ between   | $0   | &   | $0   | □ above  \u003Cbr>$0   |\n| Note:Over 8 Persons,refer to Family Size Adjustments Chart.   |  |  |  |  |  |  |  |\n\nEach family should also indicate if they are:  \n# Racial Characteristics of Family(Check allthat apply)\n\nHead of Household(Check all that apply)  \n□ White□ Black or African American □ Asian  \n□ Female  \n□American Indian or Alaska Native  \n□ Disabled  \n□ Native Hawaiian or Other Pacific Islander  \n□ American Indian or Alaska Native &White □ Asian &White  \nEthnicity(Check only one)  \n□ Black or African American &White  \n□ American Indian or Alaska Native &Black or African American  \n□ Hispanic or Latino  \n□ Not Hispanic or Latino  \n□ Other Multi-racial  \n\"Any false statements made knowingly and willfully may subject the signer to penaltiesunder Section 1001 and 1010 of Title 18 of the United States Code.”  \n(Respondent Signature)(Date)(Interviewer Signature)(Date)  \nSURVEY NO.ON ADDRESS LIST:______  \n□Refused to disclose ethnic &race informationDate of Survey Attempt:  \n1.2.3.refusedrefusedunavailableunavailable","cbCailPtdMsbdkRr","https://ap.wps.com/l/cbCailPtdMsbdkRr","pdf",221828,"English","# Survey Area & Municipality\n## Household Income by Family Size\n## Racial Characteristics of Family\n## Head of Household & Ethnicity\n## Signatures & Survey Details","[{\"question\":\"What do the signature fields cover?\",\"answer\":\"The form includes respondent signature and date, plus interviewer signature and date, and references potential penalties for knowingly false statements.\"}]","Survey Form Template 25 Update - Community Development Block Grant Eligibility | PDF",1789842341]