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EARNED INCOME 21. Give record of all places where you have worked. (Begin with most recent job) Name, Address, and Phone Number of Employer From: Mo/Day/Yr. to: Mo/Day/Yr. Reason for Leaving Date(s) Last Paid Applicant: 1. 2. 3. Spouse: 1. 2. 3. 22. Is anyone working?  Yes  No If Yes, complete and bring verification to the interview. PERSON EMPLOYED JOB TITLE EMPLOYER DATE STARTED ADDRESS PHONE HOW OFTEN PAID PAYDAY HOURS WORKED PER WEEK HOURLY RATE OF PAY GROSS PAY PER CHECK TIPS PER MONTH $ $ PERSON EMPLOYED JOB TITLE EMPLOYER DATE STARTED ADDRESS PHONE HOW OFTEN PAID PAYDAY HOURS WORKED PER WEEK HOURLY RATE OF PAY GROSS PAY PER CHECK TIPS PER MONTH $ $ PERSON EMPLOYED JOB TITLE EMPLOYER DATE STARTED ADDRESS PHONE HOW OFTEN PAID PAYDAY HOURS WORKED PER WEEK HOURLY RATE OF PAY GROSS PAY PER CHECK TIPS PER MONTH $ $ 23. Is anyone self-employed, earning money from a business, baby-sitting, out of home sales, repairing cars, swap meets, garage sales, arts, crafts, etc.?  Yes  No If Yes, complete the following and provide verification. SELF-EMPLOYED PERSON TYPE OF BUSINESS HOURS WORKED PER WEEK MONTHLY GROSS MONTHLY EXPENSES $ $ $ $ 24. Does anyone receive money from roomers or boarders?  Yes  No If Yes, complete the following: ROOMER’S BOARDER’S NAME MONTHLY AMOUNT RECEIVED ROOM BOARD $ $ $ $ $ $ 25.Does anyone expect a change in income (such as a new job, a change in wages, etc.)? Yes  No If Yes, complete the following: NAME OF PERSON EXPLAIN DATE OF CHANGE DHS 1240 (REV 04/2024) Page 7 of 11 Attachment A-2, Page 9 of 18