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If you checked the Low/Mod Housing or Low/Mod Limited Clientele Benefit box, please answer <br />the following: <br /> <br />How many Low/Mod People or Households will benefit? <br />(Please choose either people or households for each project.) <br /> <br />50 Households <br /> <br />People/Households <br /> <br />How will income be verified? <br /> <br />I'-] Income Verification Request Forms I--'] Eligibility Status for other Governmental <br /> Assistance program <br />[~ Self Certification (must inform beneficiary that all soumes of income and assets must be included when <br />calculating annual income) <br /> <br />r-] Presumed benefit (HUD presumes the following to be principally Iow and moderate-income: abused children, <br />battered spouses, elderly persons, severely disabled persons, homeless persons, persons living with AIDS, migrant farm <br />workers) <br /> <br />* For projects that directly benefit people or households, race and ethnic data must be collected as <br />well as number of female-headed households. <br /> <br />If you checked the Slum/Blight Area or Slum/Blight Spot Benefit box, please answer the <br />following: <br /> <br />What are the boundaries of the slum/blight area (i.e. census tracts, intersecting streets) or the address of <br />the slum/blight spot? <br /> <br />If Slum/Blight Area, what percent of buildings are deteriorated? <br /> <br />What deficiency will be corrected? <br />inspector noting deficiency and/or include a photo) <br /> <br />What will the public improvement be? <br /> <br />In what year did the slum/blight designation occur? <br /> <br /> % <br /> <br />(Please provide letter from city building <br /> <br />If you checked the Low/Mod Jobs Benefit box, please answer the following: <br /> <br />Will this project/activity create or retain FTEs? r-'l Create [--I Retain <br /> <br />For job(s) that are being retained, please provide evidence that the business being assisted has <br />issued a notice to affected employees or that the business has made a public announcement to that <br />effect, OR an analysis of relevant financial records that clearly shows the business is likely to have to <br />cut back on employment in the near future without the planned intervention. <br /> <br />Will the job(s) created or retained require a special skill? [--I Yes <br /> <br />[--I No <br /> <br />What percent of permanent FTEs will be held by or available to Iow/mod income persons? % <br /> <br /> <br />