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If you are completing this application on behalf of someone else, please provide the following additional information:
• Representative Name
• Phone Number
Race/Ethnicity Anglo/White Asian Black/African American Hispanic/Latino Other/Multi-Racial Other Are you a U.S. Citizen? Yes No (Please provide status at right) Primary Language English Spanish Other Are you a Veteran of the U.S. Armed Forces? Yes No EMPLOYMENT/RELATIONSHIP STATUS Highest Education Completed Less Than 12 Years GED High School Diploma Some College College Graduate Post Graduate Current Employment Status Employed full-time (30+ hours a week) Employed part-time (<30 hours a week) Retired Student Unemployed Primary Income Full-time Job Part-time Job Job Training Stipend Spouse/Partner Child Support/Alimony SS/Retirement SSI/Disability TANF Current Relationship Status Divorced Engaged Living Together/Not Married Separated Single/Never Married Widowed
If willing, would you be able to submit a drug screen?
If you have children, do you have a court order for child support?
If you have a court order for child support, do you receive it consistently?
(Include Employment Income, Child Support, Alimony, Dividends, etc.)
Include the following: Name, DOB, Age, Relationship, Gender, If child, name of father?
Have you ever applied for any government assistance, including but not limited to: No WIC TANF Food Stamps Government Subsidized Housing Shelter Other Submit