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Household Composition (continued) If you need more space to list your household members, please ask for another form or write the information on a separate sheet.

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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  SNAP  TANF

Reason for being away: 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  SNAP  TANF

Reason for being away: 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 4

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  SNAP  TANF

Reason for being away: 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

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