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F. TANF DIVERSIONARY ASSISTANCE/EMERGENCY ASSISTANCE

 YES  NO 1. Does your household have an emergency need related to basic needs (food, shelter, shelter items, potential eviction, medical expenses, childcare expenses or the costs associated with getting or keeping employment including transportations costs)? If YES, give date and explain below.

 YES  NO 2. Does anyone have emergency needs that result from a natural disaster or fire such as replacement of clothing, or the repair or replacement of household equipment and supplies which were destroyed? If YES, explain below.

 YES  NO 3. Has your household experienced an involuntary loss or reduction of income (except TANF/Refugee Cash Assistance) in the six months prior to the date of application?

 YES  NO 4. Does your household have a delay in starting to receive income resulting in the current emergency?

(The income must start within 60 days following the application date.) If YES, who? _____________________

Date, description, and cause of emergency:

G. SNAP BENEFITS

1. List the name of the person who is the head of your household: ___________________________________________________.

 YES  NO 2. Is anyone living in your home NOT included in your SNAP application? If YES, do you and everyone for whom you are applying usually purchase and prepare meals apart from these people? Or, do you intend to do so if your application for SNAP benefits is approved? Check ()  YES  NO  YES  NO 3. Is anyone living in your home renting a room from you (a roomer) or being provided a room and food (a boarder)? If YES, list names: _________________________________________________________________  YES  NO 4. Is anyone age 60 or older or approved to receive Medicaid because of a disability or receiving any type of disability payment? If YES, list all current medical expenses for these people. Household Member with Medical Expense Type of Expense Amount Name of Doctor, Hospital, Pharmacy

 YES  NO 5. Do you have any of the following shelter expenses? If YES, list your current expenses. Check () here  if these expenses are for a house that you do not live in. Expense Amount Billed How Often Billed? Who is Responsible for the Bill? Rent/Mortgage

Taxes/ Insurance

Electricity

Gas/Oil/Kerosene/Coal/Wood

Water/Sewage/Garbage

Telephone

Installation

6a How do you heat your home? _______________________________________________________________  YES  NO 6b Do you have air conditioning in your home?  YES  NO 6c Did you receive energy/fuel assistance during this past year while living in your current home?  YES  NO 6d Are you staying temporarily in someone else’s home, an emergency shelter, welfare hotel, other halfway house, or a place not usually used for sleeping? If YES, how much does it cost to stay there during the month? _______________________________________________________________________________________ If you are staying temporarily in someone else’s home, when did you move there? ______________________  YES  NO 7a Is any member of your household between the ages of 18 and 24? If YES, who? _______________________ ________________________________________________________________________________________  YES  NO 7b For any household member between the ages of 18 and 24, were they in foster care on their 18th birthday ?

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