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10. Is there anyone else living with you who is not applying for benefits? If yes, list below:
______Alien #
Name:
Relationship to You:
______Roomer
______Boarder
______Purchase &
prepare
_____Strike
11. What is the primary language spoken in your home?_____________________
12. Are you or anyone applying with you pregnant?………………………………
Yes
No
If yes, please list their name: _______________________ and due date: _____________
______Status
13. Are you or anyone applying with you unable to work?………………………
Yes
No
______Duration
If yes, who? _________________________
14. Answering this question is not required for Food Stamps.
Are you or anyone applying with you a veteran?……………………………..
Yes
No
______TPL
_____ _Retro
Personal Assets:
15. Do you or anyone applying with you have any of the following financial assets?
Asset Details
$
Checking Account
Time Certificates
Savings or Credit Union
$
401-K
Account
IRA
Money Market Funds
____Sold, traded or
given away any
Stocks
Trust Funds
resources in last 30
Bonds
Other______________________
days
None
16. Please list all vehicles owned by you or anyone applying with you. Some examples of
vehicles are cars, trucks, boats or water craft, motorcycles, snowmobiles, motor homes,
ATV’s, etc.:
Registered
Licensed
Amount
Type
Make
Year
State
owner(s)
Y/N
owed
17. Do you or anyone applying with you have any of the following assets?
Home
Land
Life Insurance
Mineral Rights
Burial Plans/Funds
Cemetery Plots
Campers
Trailers
Time Shares
Livestock
Tools
Other _____________________
Rental Property
None

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