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D. RESOURCES You do not have to complete this section if you are only applying for TANF. Otherwise, answer for everyone for whom you are applying. Include any resources anyone owns, or that are jointly owned with someone else, even if that person does not live with you. List the names of all joint owners.

1. Do you or anyone who lives with you have any of the following resources or assets?

Yes No Yes No Yes No   Cash $_________   Checking, Savings   Credit Union   401K, 403B, etc   Promissory notes   Money Market Funds   Individual Retirement Account (IRA)   Christmas Club   Deeds of Trust   Deferred Compensation Plan   Uniform Gift to Minor Account   Retirement accounts   Keogh Plan   Certificate of Deposit (CD)   Trust funds   Stocks or bonds   Pension plans   ABLE Account   Other _______________________

— If Yes to any of the above, please provide the following information: a.

Owner Name (last, first, middle initial)

Co-Owner Name (last, first, middle initial)

$ Name of Bank or Institution

Account Type

Account Number

Balance Address of Bank or Institution b.

Owner Name (last, first, middle initial)

Co-Owner Name (last, first, middle initial)

$ Name of Bank or Institution

Account Type

Account Number

Balance Address of Bank or Institution

 YES  NO 2. Has anyone received or expect to receive winnings of $4,250 or more from lottery or gambling? If YES, explain: _________________________________________________________________________________________

 YES  NO 3. Has anyone sold, transferred or given away any resources in the last 3 months (for SNAP) or in the last 3 years (for Auxiliary Grants)? If YES, explain: __________________________________________________________

E. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) (ASK FOR AN EXTRA PAGE IF YOU NEED MORE SPACE)

1. CHILD/PARENT INFORMATION

List each child for whom you are applying. Then, list the names of both parents.

You must identify both parents in order to receive TANF. If you intentionally misidentify a parent, you shall be prosecuted

2. IMMUNIZATION

(Answer only if applying for TANF.)

Has the child received ALL of the immunizations required according to the child’s age?

Check (√) Yes Or No Or Unknown Child’s Name Yes ( ) No ( ) Unknown ( ) Mother

Father Child’s Name Yes ( ) No ( ) Unknown ( ) Mother

Father Child’s Name Yes ( ) No ( ) Unknown ( ) Mother

Father

Child’s Name Yes ( ) No ( ) Unknown ( ) Mother

Father

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