Town of Rosendale Water District Household Characteristics Survey

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05-06 2021 |

YOUR RESPONSE WILL BE HELD IN THE STRICTEST CONFIDENCE
***This form is applicable to HOMEOWNERS and RENTERS***

The purpose of this survey is to determine household characteristics that will allow Town of Rosendale to qualify for grants and low interest loan funding for improvements to the Water System. Certain grant applications require race and other demographic information.

1. How many people live in this household? ____________

2. Do you own or rent the living quarters? Own ______ Rent ______

3. How many family members in the household are 62 years of age or older? ____________

4. What was your annual household income in the last tax year? ________________________

(Household income is the sum of money by all household members 18 years old or over. Income includes any sources of gross income received regularly from employment, net business or farm income, Veterans (VA) payments, unemployment compensation, child support, supplemental security income (SSI), public assistance, retirement, survivor or disability pensions, or alimony.)

5. Female head of household? (Taxpayer filing status) Yes ______ No ______

6. Are any members of the household disabled/handicapped? Yes ______ No ______ # _________

7. Year round resident? _______ Seasonal resident? _______

8. Ethnicity: (check one)

Hispanic or Latino _____

Not Hispanic or Latino _____

9. Race: (indicate number in household in the space provided)

_____ White or Caucasian

_____ Black or African American

_____ Asian

_____ American Indian or Alaska Native

_____ Black or African American and White

_____ Native Hawaiian or Other Pacific Islander

_____ Asian and White

_____ Alaska Native and Black

_____ American Indian or Alaska Native and Black or African American

_____ Multi-Racial

_____ Other

NAME: (Please Print)_____________________________________________

NAME: (Signature)_______________________________________________ Date:_____________________

ADDRESS:________________________________________________________________________________

Please complete and mail upon receipt.

Fully completing this survey will help your municipality qualify for federal and/or state funds for improvements for our Water System.

If there are any questions or concerns, please contact Supervisor Jeanne L. Walsh, 845-658-3159 x-3

Thank you for your assistance!