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Please complete information below about all household members, including yourself, in prior month.
IMPORTANT – Your applicaƟon will NOT be processed without YOUR SIGNATURE on page 3!
Page 2 of 3
More than 4 people? Use a second sheet. Household Member 1 Applicant Household Member 2 Household Member 3 Household Member 4
First + Last Name
Social Security #
\
Date of Birth
Sex Circle one per person Male Female Prefer Not to Answer Male Female Prefer Not to Answer Male Female Prefer Not to Answer Male Female Prefer Not to Answer
Race
Check one per person □ Amer Indian/Alaskan □ Amer Indian/Alaskan □ Amer Indian/Alaskan □ Amer Indian/Alaskan □ Asian □ Asian □ Asian □ Asian □ Black/African American □ Black/African American □ Black/African American □ Black/African American □ Native Hawaii/Pacific □ Native Hawaii/Pacific □ Native Hawaii/Pacific □ Native Hawaii/Pacific □ White □ White □ White □ White □ Multi-race (2+ of above) □ Multi-race (2+ of above) □ Multi-race (2+ of above) □ Multi-race (2+ of above) □ Other □ Other □ Other □ Other
Ethnicity
Check one per person □ Hispanic, Latino, or Spanish Origins □ Hispanic, Latino or Spanish Origins □ Hispanic, Latino or Spanish Origins □ Hispanic, Latino or Spanish Origins □ Non-Hispanic, Latino or Spanish Origins □ Non-Hispanic, Latino or Spanish Origins □ Non-Hispanic, Latino or Spanish Origins □ Non-Hispanic, Latino or Spanish Origins □ Unknown □ Unknown □ Unknown □ Unknown
Full Time Student?
If yes, what grade? ____
If yes, what grade? ____
If yes, what grade? ____
If yes, what grade? ____
United States Citizen?
Y N
Y N
Y N
Y N
Legally Disabled?
Y N
Y N
Y N
Y N
Health Insurance?
Y N
Y N
Y N
Y N Please indicate which household members receive any of the following monthly or annual income sources. Documented proof of income will be required, please see list on page 3 for reference Currently Employed? If yes, pay frequency?
Y N
Weekly Biweekly Monthly
Y N
Weekly Biweekly Monthly
Y N
Weekly Biweekly Monthly
Y N
Weekly Biweekly Monthly Self-Employed? (incl farm, rent, side jobs)
Y N
Y N
Y N
Y N Receiving Social Security/SSI/SSDI?
Y N
Y N
Y N
Y N Recently Unemployed? (within last 60 days) Y N If yes, last day worked________ Y N If yes, last day worked________ Y N If yes, last day worked________ Y N If yes, last day worked________ Receiving Unemployment?
Y N
Y N
Y N
Y N Receiving SNAP? (food stamps)
Y N
Y N
Y N
Y N Receiving any type DHHS Cash Assistance? e.g. FANF, TANF, APTD, FAP, etc.
Y N
Y N
Y N
Y N Earning pension, annuity, interest or dividends?
Y N
Y N
Y N
Y N IRA/401K Withdrawal within last 365 days?
Y N
Y N
Y N
Y N
Receiving Alimony?
Y N
Y N
Y N
Y N
Receiving Child Support?
Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________
Paying Child Support? Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________ Y N If yes, amount is $_______ per ________ Worker’s Comp, Short/Long Term Disability via employer?
Y N
Y N
Y N
Y N ]
Receiving VA Cash Benefits?
Y N
Y N
Y N
Y N
Receiving other income or $$ support not listed above? Help from family or friends?