PARTICIPANT SURVEY – Effective 07/2/2025

Please complete the entire form and supply the requested information or circle the correct item as it applies to you.
See attached HUD Definitions for clarification of terms: Female Head of Household, Senior, Severely Disabled and Youth.

Participant Name: 		Total Number in Household: 	
(Please Print)

Please circle the appropriate selection:	Sex:	Female	Male

Age:	18 and under (youth)	19-30	31-61	62 or older (senior)
Hispanic:	Yes	No

Single Race	or	Multi-Race	or	Other
Circle one:	White	American Indian and White Black / African American	Asian and White
Asian	African American and White
American Indian or Alaska Native	American Indian and African American Native Hawaiian or Pacific Islander

Are you Homeless?	Yes	No
Female Head of Household:	Yes	No
(Definition: a married or unmarried female who maintains a household for a dependent or non-dependent relative, and provides more than half of the dependent’s financial support.)

Are you Severely Disabled?	Yes	No	If yes, describe: 	
Income Information:	Circle family size (total number in household including foster children) then, without changing rows, Circle the amount listed to the right of the “family size” column that includes your total household income.

0BFamily Size	Income Categories (2025 Median Family Income)	
	Extremely Low (30%)	Very Low (50%)	Low (80%)	Over Income	

1	®	$ 27,800 or below	$27,801 thru $46,350	$46,351 thru $72,950	$72,951 or above	

2	®	$31,800 or below	$31,801 thru $53,000	$53,001 thru $83,400	$83,401 or above	

3	®	$35,750 or below	$35,751 thru $59,600	$59,601 thru $93,800	$93,801 or above	

4	®	$39,700 or below	$39,701 thru $66,200	$66,201 thru $104,200	$104,201 or above	

5	®	$42,900 or below	$42,901 thru $71,500	$71,501 thru $112,550	$112,551 or above	

6	®	$46,100 or below	$46,101 thru $76,800	$76,801 thru $120,900	$120,901 or above	

7	®	$49,250 or below	$49,251 thru $82,100	$82,101 thru $129,250	$129,251 or above	

8	®	$54,150 or below	$54,151 thru $87,400	$87,401 thru $137,550	$137,551 or above	

Talk to agency staff for help in determining income category for your household.

More than 8

I certify that the information on this form is accurate and complete. I authorize (		 / Anoka County) to verify the information provided if necessary.	Agency Name

Signature of Participant	Date

Warning: Section 1001 of Title 18 of US. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as to matters within its jurisdiction.

HUD Definitions

Female Head of Household: a married or unmarried female who maintains a household for a dependent, or non-dependent relative, and provides more than half of the dependent’s financial support.
Senior:	a person 62 years or older.

Severely Disabled: If you 1) use a wheel chair or another special aid for 6 months or longer; or,
2)	are unable to perform one or more functional activities (seeing, hearing, having one’s speech understood, lifting and carrying, walking up a flight of stairs, and walking), or need assistance with activities of daily living (getting around inside the home, getting in or out of bed or a chair, bathing, dressing, eating or toileting) or instrumental activities of daily living (going outside the home, keeping track of money or bills, preparing meals, doing light housework and using the telephone); or
3)	are prevented from working at a job or doing housework; or,
4)	have a selected condition including autism, cerebral palsy, Alzheimer’s disease, senility, dementia or mental retardation; or,
5)	are under 65 years of age and are covered by Medicare or receive Supplemental Security Income (SSI).

Youth:	a person 17 years or younger.

For Agency use only:
(Participant does not complete)

Income determination for households of more than 8 members:
Per HUD, family sizes in excess of 8 persons are calculated by adding eight percent (8%) of the four-person income limits for each additional family member. So:
•	9-person household should be 140% of the 4-person limit;
•	10-person household should be 148% of the 4-person limit;
•	11-person household should be 156% of the 4-person limit;
•	12-person household should be 164% of the 4-person limit; and so on.

If conflicting information is provided on Survey form, please explain here: