Salem Township/Slate Stone Road

1. Salem Township/Slate Stone Road Salary Survey

As a resident of Slate Stone Road, you are being asked to complete this Salary Survey so that Salem Township can qualify for Community Development Block Grant (CDBG) available through the County from the State. Should the township qualify for the program, the funds received will be specifically used to make improvements to Slate Stone Road.

If you have any questions about this process, please contact one of the township contacts listed in the letter you received. You may also contact the LUC Regional Planning Commission at 937-666-3431.

Thank you.

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* 1. Date of Survey

Date Survey Taken:

Date

Question Title

* 2. Address of Household

Question Title

* 3. Total Number of Household Members (include yourself, spouse, children, etc)

Question Title

* 4. Income Limit Ranges

	Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$0 - $12,550	$0 - $12,550 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$12,551 - $20-950	$12,551 - $20-950 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$20,951 - $33,500	$20,951 - $33,500 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$33,501 - $38,300	$33,501 - $38,300 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$38,301 - $43,050	$38,301 - $43,050 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$43,051 - $47,850	$43,051 - $47,850 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$47,851 - $51,700	$47,851 - $51,700 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$51,701 - $55,500	$51,701 - $55,500 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$55,501 - $59,350	$55,501 - $59,350 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$59,351 - $63,150	$59,351 - $63,150 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
$63,151 and above	$63,151 and above Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range
Above $63,151	Above $63,151 Income Range of Household (Total Gross annual Income of All Perons) Check the box below that corresponds to your household's income range