Water Improvement Project Survey

1. Name

Name

2. Physical Address

Physical Address

3. Do You

Do You Rent

Own

4. Number of people in the household (check one)

Number of people in the household (check one) 1

5. Are there any elderly (62 years or older) persons residing here?

Are there any elderly (62 years or older) persons residing here? Yes

If yes, how many?

6. Are there persons living here that are handicapped?

Are there persons living here that are handicapped? Yes

If yes, how many?

7. How many children (under 18) live in the household

How many children (under 18) live in the household

8. Annual Household Income*

**Household income is defined as income of all adult (18 and older) household members received from all sources such as wages, salaries, interest income, investment income, social security, public assistance, or other sources. One method for calculating household income is to use the adjusted gross income from your most recent tax return form for all adults in the household.

Annual Household Income* **Household income is defined as income of all adult (18 and older) household members received from all sources such as wages, salaries, interest income, investment income, social security, public assistance, or other sources. One method for calculating household income is to use the adjusted gross income from your most recent tax return form for all adults in the household. Less Than $32,200

$32,201 - $36,800

$36,801 - $41,400

$41,401 - $46,000

$46,001 - $49,700

$49,701 - $53,350

$53,351 - $57,050

$57,051 - $60,700

More than $ 60,701

Water Improvement Project