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PART II: HOUSEHOLD MEMBERS, INCOME AND RESOURCES

List ALL persons normally living and eating with you as of the date of this application. Do not include any persons temporarily staying with you or with whom you are temporarily staying. If members of your family are not together today because of circumstances directly related to the disaster, but they were living and eating with you on the date of the disaster, including those persons also.

Enter the total amount of ALL earned and unearned income received or expected to be received for ALL household members during the DISASTER BENEFIT PERIOD indicated above. Income includes, but is not limited to, gross salary and wages for full and part-time jobs, pensions, self-employment, child support, Social Security death, retirement, and disability benefits, and Supplemental Security Income. Source means: for wages- name of employer, for self-employment- name of business, and for child support- name of payor. Do not include disaster assistance payments you expect to receive from federal, state, or local governments or disaster assistance agencies during the benefit period. List all income including any received for a child or children in your household.

Enter the amount of ALL accessible resources as of the date of this application for ALL household members. Resources include, but are not limited to, cash on hand, money in checking and regular savings accounts, certificates of deposit, money market accounts, and Christmas and Vacation Club accounts. Resources do NOT include IRA Accounts, stocks, bonds, and KEOGH Plans. Source means: for all types, except cash on hand, the name of the financial institution. Please be sure to enter an answer in every row. If a person does not have the income or resource type listed, enter NA for not applicable.

IF YOU NEED TO INCLUDE ADDITIONAL HOUSEHOLD MEMBERS, INCOME, OR RESOURCES, PLEASE ASK FOR ANOTHER COPY OF THIS PAGE.

List Head of Household under 1. List other household members under 2 through 5. List a Social Security Number (SSN) and date of birth (DOB) for all members. List an amount and source (if applicable) for each income and resource type listed below. TYPE

1.NAME (Last, First, MI, Suffix):

2.NAME (Last, First, MI, Suffix):

3.NAME (Last, First, MI, Suffix):

4.NAME (Last, First, MI, Suffix):

5.NAME (Last, First, MI, Suffix):

SSN: SSN: SSN: SSN: SSN: DOB: DOB: DOB: DOB: DOB: DISASTER BENEFIT PERIOD ___________ to___________ INCOME AMOUNTS GROSS WAGES/SALARY AMOUNT

SOURCE

NET SELF- EMPLOYMENT AMOUNT

SOURCE

CHILD SUPPORT AMOUNT

SOURCE

SOCIAL SECURITY (DEATH, RETIREMENT, DISABILITY AMOUNT

SOURCE

PENSION AMOUNT

SOURCE

SUPPLEMENTAL SECURITY INCOME AMOUNT

SOURCE

OTHER INCOME (SUCH AS VETERANS, UNEMPLOYMENT, TANF) LIST ALL INCOME INCLUDING ANY RECEIVED FOR A CHILD OR CHILDREN IN YOUR HOUSEHOLD. AMOUNT

SOURCE