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INCOME (continued)

 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 since you applied? 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   VA benefits   Strike benefits

  Child support, alimony   Unemployment benefits   Prize winnings

  Cash gifts or contributions   Room/board income   All food, clothing, utilities, or rent

  Loans   Black Lung benefits   Other retirement

  SSI   Worker compensation   Interest, dividends

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

  Public Assistance (TANF, GR etc)   Inheritance   Any other type of money

  Training allowances (WIA, etc.)   Railroad retirement

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 not in the household? If YES, give name of person paying, person supported, and amount: _________________________________________________________ _________________________________________________________________________________________

D. FINANCIAL ASSISTANCE FOR CHILDREN  YES  NO 1. Has the absent parent(s) begun supporting the children or changed the amount of support? If YES, explain: __________________________________________________________________________  YES  NO 2. Has the legal parent(s) become disabled such that he or she is unable to work? If YES, explain: _______________________________________________________________________________________  YES  NO 3. Do you have any new information that would help us locate the absent parent(s)? If YES, explain; _______________________________________________________________________________________

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