Complete all sections and attach requested documentation; failure to do so will delay eligibility determination.
attach a copy of ID(e.g. driver's license) and Social Security Card
Please list the other persons living in your household but not yourself. Please provide all of the information for each individual.
WORK INCOME - List anyone in your household (18 and older) who has work income (includes self‐employment, babysittng,
and other odd jobs). List additional information on a separate sheet, if necessary. ATTACH PROOF OF INCOME.
B. LAST EMPLOYMENT - If you or any adult (18 or older) member of your household is unemployed at the time of this application, list the most recent employment below.
C. NON-WORK INCOME - List anyone in your household who receives any of the following and attach proof of this income:Alimony | Child Support | Housing Utility Assistance Payment | Retirement Benefits | Social Security Income (SSA) | Supplemental Security Income (SSI) | Supplemental Security Disability Income (SSDI) | TEA | Unemployment Benefits | Veteran's Benefits | Worker's Compensation | Any other non-work income
D. RESOURCES - Does anyone in your home have any of the following?
If your household is in need of crisis assistance, please indicate below:
You must attach proof of identity. Acceptable proof includes A READABLE COPY of any VALID document that reasonably establishes identity such as: