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B. HOUSEHOLD COMPOSITION: This section includes information about everyone living in your home, even if you are not applying for that person. You may leave the Social Security Number blank if you are not applying for assistance for the person. List yourself first. 1

Self

Name (last, first, middle initial)

Relationship to You

Birth Date (mm-dd-yyyy)

Social Security Number: _________________________

City, State, Country of Birth: ____________________________ Gender:  Male  Female

Are you a U.S. citizen?  Yes  No Marital Status:  Married  Never Married

If No, immigration status: ____________________________  Separated  Divorced  Widowed

US Residency Date: __/____/____ Highest Grade Completed: ____

Alien Registration Number: _________________________ School Name if a Student: _______________________

Are you disabled or pregnant?  Yes  No Are you a veteran or dependent?  Yes  No:

Are you temporarily living away from home?  Yes  No Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____  None  AG  GR  RCA  SNAP

Reason for being away:  TANF  TANF DA or EA  TANF--No SNAP

Providing the following information is voluntary and will not affect eligibility. Please check all that apply. Ethnicity:  Hispanic/Latino  Not Hispanic/Latino Racial Heritage:  White  Black/African American  Asian  Asian & Black/African American  Asian & White

 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White

 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown 2

Name (last, first, middle initial)

Relationship to Applicant

Birth Date (mm-dd-yyyy)

Social Security Number: _________________________

City, State, Country of Birth: ____________________________ Gender:  Male  Female

Is this person a U.S. citizen?  Yes  No Marital Status:  Married  Never Married

If No, immigration status: ____________________________  Separated  Divorced  Widowed

US Residency Date: __/____/____ Highest Grade Completed: ____

Alien Registration Number: _________________________ School Name if a Student: _______________________

Is this person disabled or pregnant?  Yes  No Is this person a veteran or dependent?  Yes  No

Is this person temporarily away from home?  Yes  No Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____  None  AG  GR  RCA  SNAP

Reason for being away:  TANF  TANF DA or EA  TANF--No SNAP

Providing the following information is voluntary and will not affect eligibility. Please check all that apply. Ethnicity:  Hispanic/Latino  Not Hispanic/Latino Racial Heritage:  White  Black/African American  Asian  Asian & Black/African American  Asian & White

 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White

 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown 3

Name (last, first, middle initial)

Relationship to Applicant

Birth Date (mm-dd-yyyy)

Social Security Number: _________________________

City, State, Country of Birth: ____________________________ Gender:  Male  Female

Is this person a U.S. citizen?  Yes  No Marital Status:  Married  Never Married

If No, immigration status: ____________________________  Separated  Divorced  Widowed

US Residency Date: __/____/____ Highest Grade Completed: ____

Alien Registration Number: _________________________ School Name if a Student: _______________________

Is this person disabled or pregnant?  Yes  No Is this person a veteran or dependent?  Yes  No

Is this person temporarily away from home?  Yes  No Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____  None  AG  GR  RCA  SNAP

Reason for being away:  TANF  TANF DA or EA  TANF--No SNAP

Providing the following information is voluntary and will not affect eligibility. Please check all that apply. Ethnicity:  Hispanic/Latino  Not Hispanic/Latino Racial Heritage:  White  Black/African American  Asian  Asian & Black/African American  Asian & White

 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White

 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown 2