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D. INCOME  YES  NO 1. Do you or anyone applying for ESAP with you receive or expect to receive money from working? If YES,

$

Name of Person

Amount/ How Often Received?

Employer 2. Do you or anyone applying for ESAP with you 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 or SSI   Worker compensation   Room/board or Rental Income

  VA benefits or Military Allotment   Unemployment benefits   Interest, dividends

  Child support, alimony   Black Lung benefits   Public Assistance (TANF/GR)

  Railroad or Other retirement   Insurance settlement   Any other type of money 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?

E. EXPENSES  YES  NO 1. Do you have any of the following shelter expenses? If YES, list your current expenses. Check () here  if these expenses are for a house you do not live in. Expense Amount Billed How Often Billed? Who is Responsible for the Bill? Rent/Mortgage

Taxes/ Insurance

Electricity

Gas/Oil/Kerosene/Coal/Wood

Water/Sewage/Garbage

Telephone

Other

 YES  NO 1a Do you have air conditioning in your home? How do you heat your home? ___________________________  YES  NO 1b Did you receive energy/fuel assistance during this past year while living in your current home?  YES  NO 2. Do you or anyone in your household who is age 60 or older have any current medical expenses? If YES, list the expenses. This may include prescriptions, health insurance premiums, transportation, or doctor visit payments. Household Member with Medical Expense Type of Expense Amount Name of Doctor, Hospital, Pharmacy

 YES  NO 3. 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 4. Does anyone pay legally obligated child support to someone who is not in the household? If YES, give name of person paying, person supported, and amount: ___________________________________________________

BY MY SIGNATURE BELOW, I DECLARE: I have given true and correct information on this application to the best of my knowledge and belief. I understand that if I give false information, withhold information, or fail to report a change promptly or on purpose, I may be breaking the law and could be prosecuted for perjury, larceny, and/or welfare fraud.  I allow  I do not allow the Department of Social Services to disclose certain information about me to other state agencies, including information in electronic databases, for the purpose of determining my eligibility for benefits/services provided by that agency. This disclosure will make it easier for agencies to work together efficiently to provide or coordinate services and benefits. Agencies include, but are not limited to, the Department of Health, and the Department for Aging and Rehabilitative Services. I can withdraw this authorization at any time by notifying my eligibility worker.

_________________________________________________________ ________________________________

Signature of Applicant or Authorized Representative Date

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