Page 626

B. HOUSEHOLD COMPOSITION: This section includes information about everyone living in your home, even if you are not applying for that person. You may leave the Social Security Number blank if you are not applying for assistance for the person. List yourself first. If you need more space to list your household members, please ask for another form or write the information on a separate sheet. 1

Self

Name (last, first, middle initial)

Relationship to You

Birth Date (mm-dd-yyyy)

Social Security Number:_________________________

City, State, Country of Birth:_____________________________ Gender:  Male  Female

Are you a U.S. citizen?  Yes  No Program Requested:

If No, immigration status: ____________________________  None  ESAP

US Residency Date: __/____/____

Alien Registration Number:_________________________ 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 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 Program Requested:

If No, immigration status: ____________________________  None  ESAP

US Residency Date: __/____/____

Alien Registration Number:_________________________ 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 Are there others who live in your home? If YES, Name of Person

Relationship

Does this person buy/eat food with you?

 Yes  No

 Yes  No

 Yes  No

C. RESOURCES

1. Do you or anyone who lives with you have any of the following resources or assets? If Yes, please provide details below.

Yes No Yes No Yes No   Cash $_________   Checking/Savings Accounts   Stocks or bonds   401K, 403B, etc   Certificate of Deposit (CD)   Money Market Funds   Individual Retirement Account (IRA)   Christmas Club   Other a.

Owner Name (last, first, middle initial)

Co-Owner Name (last, first, middle initial)

$ Name of Bank or Institution

Account Type

Account Number

Balance Address of Bank or Institution b.

Owner Name (last, first, middle initial)

Co-Owner Name (last, first, middle initial)

$ Name of Bank or Institution

Account Type

Account Number

Balance Address of Bank or Institution

 YES  NO 2. Has anyone received or expect to receive winnings of $4,500 or more from lottery or gambling? If YES, explain: _________________________________________________________________________________________

 YES  NO 3. Has anyone sold, transferred or given away any resources in the last 3 months? If YES, explain: _________________________________________________________________________________________ 2