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Household Composition (continued)
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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 6
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
YES NO 1. Have any of your children received any immunizations since approval of your original application or since your most recent review? If YES, explain: ____________________________________________________________
YES NO 2. Have you or anyone for whom you are applying ever been disqualified from receiving TANF (AFDC) or SNAP benefits? If YES, explain: ____________________________________________________________________
YES NO 3. Is anyone in violation of parole or probation or fleeing capture to avoid prosecution or punishment of a felony? If YES, explain: ______________________________________________________________________________
YES NO 4. Have you or anyone for whom you are applying ever been convicted of a felony as an adult on or after February 8, 2014 for the following: e. Aggravated sexual abuse under Title 18 United States Code (USC), Section 2241 or a similar state offense? YES NO f. Murder under Title 18 USC, Section 1111 or a similar state offense? YES NO g. An offense under Title 18 USC, Chapter 110 (sexual exploitation and other abuse of children) or a similar state offense? YES NO h. A federal or state offense involving sexual assault, as defined in Section 40002(a) of the Violence Against Women Act of 1994 (42 USC 13925(a)) ? YES NO If YES to any of the above, who? __________________________________________. If YES to any of the above, are you in compliance with the terms of the sentence? YES NO
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