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Refer to codes below for responses to questions marked with the corresponding asterisk symbols (*) 1. HOUSEHOLD MEMBERS On line #1, enter the name of the primary person who will receive the money and/or SNAP benefits for your household. If spouse is in the household, list spouse on line #2. Then list the other household members who are applying for assistance. For money assistance applicants, if anyone in the home is pregnant, list “unborn child” as a household member. All other household members not applying for assistance shall be listed under section #2. Last Name, First, M.I. SEX M/F (*) BIRTHDATE MO/DAY/YR SOCIAL SECURITY NUMBER (42 USC 1320b-7 requires that SSN’s be provided for each household member applying for assistance. (**) (***) (****) YES or NO D I S A B L E D H I G H E S T G R A D E NAME OF CHILD’S PARENT(S) IF NOT IN THE HOME (SKIP IF APPLYING ONLY FOR SNAP) Was child’s mother married to child’s father at time of birth? R E L A T I O N S H I P T O P E R S O N # 1 E T H N I C R A C E M A R I T A L S T A T U S C O M P L E T E D (Check one) Yes No 1. OTHER NAMES USED AGE: 2. OTHER NAMES USED AGE: 3. OTHER NAMES USED AGE: 4. OTHER NAMES USED AGE: 5. OTHER NAMES USED AGE: 6. OTHER NAMES USED AGE: 7. OTHER NAMES USED AGE: 8. OTHER NAMES USED AGE: 2. HOUSEHOLD MEMBERS WHO DO NOT WANT HELP Write in the names of others in your home who do not want assistance (include yourself if you do not need help.) These people do not need to give us information about their citizenship, immigration status or social security number. These people will not be considered applicants and will not be eligible, however, they may need to tell us about their income and answer the other questions on this form. 1. AGE: 2. AGE: 3. AGE: 4. AGE: 3. Is anyone temporarily out of the home? Yes No Name Date Left Date to Return Where Person Went (*) Relationship Codes to Person #1: (**) Ethnic Codes - Select only one code (***) Marital Status Codes: SP - Spouse PA - Parent CH - Child SI - Sibling AU - Aunt/Uncle NN - Niece/Nephew GR - Grandparent GC - Grandchild NR - Not Related OR - Other Related UB - Unborn FC - Foster Child EX - Ex-Spouse SS - Step Sibling ST - Step Parents CL - Common Law CO - Cousin SC - Step Child HI - Hispanic NH- Not Hispanic NM - Never Married ML - Married, Living with Spouse DI - Divorced LS - Legally Separated MS - Separated MI - Married, Involuntary Separation WI - Widowed CL - Common Law (***) Race Codes - Select one or more codes below WH - White BL - Black AI - American Indian or Alaskan Native HA - Hawaiian SA - Samoan JA - Japanese KO - Korean CH - Chinese FI - Filipino OA - Other Asian OP - Other Pacific Islanders (This question is optional to answer. Failure to answer will not affect eligibility) DHS 1240 (REV 04/2024) Page 2 of 11 Attachment A-2, Page 4 of 18