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10. What is the primary language spoken in your home? How well is English spoken in the home? (Check only one box) Does not speak or understand English Limited understanding Speaks well, does not read or write English Speaks well, limited reading and writing skills Speaks well, adequate reading and writing skills Do you need an interpreter? If needed, an interpreter will be provided free of charge. Yes. What language: No. I will provide my own interpreter or have a family member or friend who can interpret for me. 11. Has anyone ever received financial or SNAP assistance? Yes No NAME Type of Assistance Date Last Received County/State Last Received 12. Has any household member been disqualified from the SNAP or financial assistance programs? Yes No If yes, list name, program, disqualification period, county, and state. NAME PROGRAM DISQUALIFICATION PERIOD COUNTY/STATE 13. For SNAP applicants/recipients only: if you are age 18 through 52 and are an able-bodied adult without dependents (ABAWD), you will only be eligible for three months of assistance in a 36-month period unless you meet additional work/training requirements. You must be employed or participating in an eligible work/training program for 20 hours weekly. Have you participated in a job training program under the Employment and Training (E&T) program, Workforce Investment Act or Trade Adjustment Assistance Act? Yes No NAME Job or Training Program Participation Dates 14. Is anyone on strike? Yes No If yes, name? 15. List the person(s) who is needed in the home to care for a disabled person. DHS 1240 (REV 04/2024) Page 4 of 11 Attachment A-2, Page 6 of 18