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L <br />Tobacco communities Reinvestment Fund <br />2010 Qemonstration Award Program <br />Intake Survey <br />The following information is collected, sa that RAFT can have a better understanding of who is <br />participating in the grant program. The information is helpful to RAFI in finding resources to continue <br />the program. AEI information that you provide in this survey is anonymous. Your name will never be <br />associated with the data. We thank you for your help. <br />Please provide the following information for yourself and your spouse or other family members who <br />are collaborating on your project with you: <br /> Yourself Spouse or Other Family Members <br />Ethnicity: <br />Gender: <br />Age: <br />Number of Acres Farmed: <br />Total Household Income: <br />Gross Farm Income: <br />County (or counties) farmed: <br />Have you earned income from <br />tobacco? Were you a grower or <br />quota holder? <br />Please return this survey to RAFT-USA, PO Box 640, Pittsboro,lVC 27312. <br />AJ! information that you provide in this survey wilf be kept anonymous. <br />