Income Information

 
Income is counted for anyone 18 or older. If the income is unearned, such as a grant of benefit, it is still counted for all household members including minors.

Include all income anticipated for the next 12 months.

Do you, or anyone in your household receive, or expect to receive income from:

1. Employment wages or salaries?
(Include overtime, tips, bonuses, commissions and payments received as cash.)
YesNo

2. Self-employment?
(Include overtime, tips, bonuses, commissions and payments received as cash.)
YesNo

3. Unemployment benefits or worker’s compensation?
YesNo

4. Public Assistance, General Relief or Aid to Families with Dependent Children?
YesNo

5a. Child support or Alimony?
(We must count court-ordered support whether or not it is received unless legal action has been taken to remedy. We must also count support that is not court-ordered but received directly from the payor.)
YesNo

6. Social Security, SSI or any other payment from Social Security Administration?
YesNo

7. Regular payments from Veteran’s, pension, or retirement benefits or annuities?
YesNo

8. Regular payments from a severance package?
YesNo

9. Regular payments from any type of settlement?
(For example, insurance settlements.)
YesNo

10. Regular gifts or payments from anyone outside of the household?
(This includes anyone supplementing your income or paying any of your bills.)
YesNo

11. Educational grants, scholarships, or other student benefits?
YesNo

12. Regular payments from lottery winnings or inheritances?
YesNo

13. Regular payments from rental property or other real estate transactions?
YesNo

14. Any other income sources or types not listed?
YesNo

15. Do you or any other household member(s) expect any changes to your income in the next 12 months?
YesNo

Asset Information

 
Please include all assets held and the income derived from the asset. Include all assets held by all household members including minors.

Do you or anyone in your household hold:

1. A checking or savings account?
YesNo

2. CD’s, money market accounts, or treasury bills?
YesNo

3. Stocks, bonds, or securities?
YesNo

4. Trust Funds?
YesNo

5. IRA’s, Keogh, or other retirement accounts?
YesNo

6. Cash on hand over $500?
YesNo

7. Real estate, rental property, land contracts/contract for deeds or other real estate holdings?
YesNo

8. Personal property held as an investment?
(Art, jewelry, etc.)
YesNo

9. Whole Life Insurance Policies?
YesNo

10. Have you or any other household members disposed of or given away and asset(s) for less than fair market value within the past 2 years?
YesNo

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