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Personal Information

Applicant Name*

Applicant Email*

Applicant Social Security Number*

Spouse Name

Spouse Social Security Number

Street Address*

Apt #

City*

State*

Zip Code*

Home Phone*

Work Phone

Cell Phone

Gender*

FemaleMale

Date of Birth*

Ethnicity*

African AmericanLatino or HispanicNative AmericanCaucasianAsian, Pacific IslanderOther

If Other, please specify

Highest Level of Education Completed*

Grade K-5Grade 6-8Grade 9-12High School Diploma or GEDGraduated Junior College (2 years)Attended CollegeGraduated College (4 years)Attended Graduate School

Household Information

"Household" includes 1) your financial dependents (for example your dependent children) 2) anyone you depend on financially (for example, your parents) or 3) anyone with whom you are financially interdependent (for example your spouse or partner). Your "household" may or may not be the same as the people you live with.

How many adults (18 yrs. and older) currently live in participant's household?*

How many children (under 18 yrs.) currently live in participant's household?*

Applicant's Marital Status*

Single (Never Married)MarriedSeparatedDivorcedWidowed

What is the primary language spoken in your household?*

In not English, is English also spoken?
—Please choose an option—yesno

Assets & Liabilities

Do you own a vehicle(s)?*

YesNo

Value of vehicle(s)

Outstanding Vehicle Loan(s)

Do you own a home?*

YesNo

Value of home

Outstanding Mortgage

Do you own residential rental property or land?*

YesNo

Value of Property

Outstanding Property Loan(s)

Do you own stocks, bonds, a 401K, or other investment?*

YesNo

Value of Investments

Do you have a checking account?*

YesNo

Amount in account

Do you have a savings account?*

YesNo

Amount in account

Do you owe money to family or friends?*

YesNo

Amount you owe

Do you have past due household bills?*

YesNo

Amount outstanding

Are you carrying a balance on a credit card(s)?*

YesNo

Amount of balance

Do you have outstanding student loans?*

YesNo

Outstanding Loan(s)

Do you have outstanding medical bills?*

YesNo

Outstanding balance

Income Information

Income of all household members - please list gross income before taxes.

Formal Employment (wages)

Last Month*



Typical Month*



Last Year*

Self-Employment

Last Month*



Typical Month*



Last Year*

Government Assistance (TANF, Food Stamps, SSI, SSA, unemployment, or Veterans benefits)

Last Month*



Typical Month*



Last Year*

Pension or retirement

Last Month*



Typical Month*



Last Year*

Child support/ alimony payments

Last Month*



Typical Month*



Last Year*

Friends or Family

Last Month*



Typical Month*



Last Year*

Investment Income

Last Month*



Typical Month*



Last Year*

Other (Please Specify)

Last Month*



Typical Month*



Last Year*

Employment Information

Primary Employment Status (choose one)*

Employed more than full-time (overtime or more than one job, for yourself of others)Employed full-time (for yourself or others)Employed Part-time(for yourself or others)Working and in school or job trainingDisabled, not seeking employmentCurrently in school or job trainingHomemaker, not seeking employmentRetired, not seeking employment

Employer*

Employer Phone*

Employer Street Address*

Employer State*

Employer Zip*

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