Page 5 - Full_Application_for_print

Assistance Application

Page 2

Military status, Disconnected youth, Wages and Benefits Information

Circle the correct reponses

Houshold members listed on Page 1: Military Status Age Youth Working In School Wages? Benefits?
1 YNYNYNYN
2  Veteran  None YNYNYNYN
3  Active  Other YNYNYNYN
4  Veteran  None YNYNYNYN
5  Active  Other YNYNYNYN
6  Veteran  None YNYNYNYN
7  Active  Other YNYNYNYN
8  Veteran  None YNYNYNYN
 Active  Other
 Veteran  None
 Active  Other
 Veteran  None
 Active  Other
 Veteran  None
 Active  Other
 Veteran  None
 Active  Other

Wage and Benefit Source Information

Instructions: List all wages and benefits for all household members.
Work status choices: Full Time (FT), Part Time (PT), Migrant or Seasonal Farmworker (MS), Retired (R),
Unemployed for 6 months or more (U6M), Unemployed for 6 months or less (U6L), not in labor force (NLF)

Houshold members listed on Page 1: Income Source How often paid Total Monthly Income Status

1

2

3

4

5

6

7

8

Government Benefits Information - Not used to determine eligibility; for reporting purposes only.

Does anyone in the household receive any of these? (mark all that apply)

Employment pay Social Security
SSI Child Support
TANF Food Stamps
Unemployent benefits General Assistance
VA Benefits Other:

Housing Information

The home is: Owned Rented Type: House Apartment Payment / Mo

Landlord: Mobile Home Other

Address: Phone

City: State: Zip County

Are utilities included in the rent? Yes No Is there a utility allowance received? Yes No

Is there any subsidy for the housing? No HUD Section 8 Public Housing Other

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