2023 Community Development Block Grant Target Survey

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2023 Community Development Block Grant Target Area Survey

Resident Name *

Street Address *

No PO Box 3; if duplex, list letter, number, etc.

City, State *

Zip Code *

Date of Survey *

Check One *

Resident Status *

Total Number of Persons in Household *

Total Number of Hispanic Persons in Household *

# of White/Caucasian in Household

# of Black/African American in Household

# of Asian in Household

# of American Indian/Alaskan Native in Household

# of Native Hawaiian/Other Pacific Islander in Household

# of American Indian/Alaskan Native & White in Household

# of American Indian/Alaskan Native & Black/African American in Household

# of Black/African American & White in Household

# of Asian & White in Household

# of Other Multi-Racial in Household

# of Persons in Household with a Disability *

# of Persons 62 Years of Age or Older in Household *

Is the Head of Household Female? *

Total Annual Household Income (Select One) *

Participant Signature *

First

Last

Note this is a digital signature.

Phone Number *