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C. INCOME

1. Do you or anyone who lives with you receive or expect to receive any of the following types of money from working? Include money from all jobs that you have now or expect to begin, full time, part time, seasonal, temporary, self-employment. Answer Yes or No below and provide the requested information:

Yes No Yes No Yes No

  Wages/Salary   Earned Sick Pay   Domestic Work

  Contract Income   Babysitting/Child or Adult Care   Self-employment

  Vacation Pay   Farming/Fishing   Any other money from

  Commissions, Bonuses, Tips   Odd jobs

working a.

Name (last, first, middle initial)

Employer Name, Address and Telephone Number

Pay Schedule Number of Hours Per Week

Rate of Pay

 Weekly  Monthly

 Biweekly  Other  Twice a Month Date Job Started

Next Pay Date (mm-dd-yyyy)

b.

Name (last, first, middle initial)

Employer Name, Address and Telephone Number

Pay Schedule Number of Hours Per Week

Rate of Pay

 Weekly  Monthly

 Biweekly  Other  Twice a Month Date Job Started

Next Pay Date (mm-dd-yyyy)

 YES  NO 2. Has anyone been fired, laid off, gone on sick or maternity leave, gone on strike, quit a job, or reduced hours worked in the last 60 days? If YES, give name and explain: _________________________________________ _________________________________________________________________________________________ 3. Do you or anyone who lives with you (including children) receive or expect to receive any of the following? Answer yes or no below and provide the requested information.

Yes No Yes No Yes No

  Social Security   Cash gifts or contributions   Strike benefits

  SSI   Unemployment benefits   Prize winnings

  VA benefits   Room/board income   All food, clothing, utilities, or rent

  Child support, alimony   Black Lung benefits   Other retirement

  Public Assistance (TANF, GR, etc.)   Worker compensation   Interest, dividends

  Military Allotment   Rental Income   Insurance settlement

  Training allowances (WIA, etc.)   Inheritance   Refugee Matching Grant

  Loans   Railroad retirement   Any other type of money a. $

Name of Person

Amount

Type of Money or Help

How Often Received?

b.

$

Name of Person

Amount

Type of Money or Help

How Often Received?

c.

$

Name of Person

Amount

Type of Money or Help

How Often Received?

 YES  NO 4. Does anyone besides the people on your case pay directly for you, help you pay, or lend you money to pay rent, utilities, medical bills or any other bills? OR does anyone totally supply food, shelter or clothing for you or someone else on a regular basis? If YES, give name, amount, and explain: ____________________________ _________________________________________________________________________________________  YES  NO 5. Does anyone have a day care expense for a child, an elderly person, or an adult with a disability? If YES, give name, amount and explain: ___________________________________________________________________ _________________________________________________________________________________________  YES  NO 6. Does anyone pay legally obligated child support to someone who is not in the household? If YES, give name of person paying, person supported, and amount: ___________________________________________________ _________________________________________________________________________________________

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