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COMMONWEALTH OF VIRGINIA Case Number ________________

Date Received _______________

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM (TANF) APPLICATION TO ADD NEW ASSISTANCE MEMBERS This is an application to add new assistance unit members for the TANF Program. These new members joined the family unit since the last application was filed. You may bring this application to the local Department of Social Services office or mail it to the local Department of Social Services office. A. Your Contact Information

Your Name (last, first, middle initial)

Your Street Address (include apartment number)

City, State, ZIP

Your Mailing Address (if different from your street address)

City, State, ZIP

In what city or county do you live?

E-mail Address

Primary Telephone Number

Alternate Telephone Number B. New Household Member Information Give the following information for any new household members you are reporting for the first time or for new members you verbally reported since your original application or most recent eligibility review. 1.

Name (last, first, middle initial)

Relationship to You

Date of Birth (mm-dd-yyyy)

Social Security Number:_________________________

Assistance Requested:  SNAP Benefits  TANF  None Gender:  Male  Female

Place of Birth:________________________________________ (City, State, Country) Marital Status:  Married  Never Married  Separated  Divorced  Widowed

Is this Person a U.S. Citizen?  Yes  No — If not a U.S. Citizen, what is your status? _________________ Is this Person a Student?  Yes  No If yes, name of school ____________________________

Alien Registration Number _____________________________ Highest Grade Completed _______________________

Date started living in the U.S. (mm-dd-yyyy) _____/____/________ 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

2.

Name (last, first, middle initial)

Relationship to You

Date of Birth (mm-dd-yyyy)

Social Security Number:_________________________

Assistance Requested:  SNAP Benefits  TANF  None Gender:  Male  Female

Place of Birth:________________________________________ (City, State, Country) Marital Status:  Married  Never Married  Separated  Divorced  Widowed

Is this Person a U.S. Citizen?  Yes  No — If not a U.S. Citizen, what is your status? _________________ Is this Person a Student?  Yes  No If yes, name of school ____________________________

Alien Registration Number:_____________________________ Highest Grade Completed:_______________________

Date started living in the U.S. (mm-dd-yyyy) _____/____/________ 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

032-03-729B-16-eng (05/2020)