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OFFICE USE ONLY
18. Do you or anyone applying with you have any of the following unearned income?
Income Details
Social Security
Retirement
SSI
Workers’ Compensation
Unemployment Benefits
Veterans’ Benefits
Child Support
Alimony
Lump Sum Payments
Inheritances
Settlements
Other ____________________
School Financial Aid
None
19. Do you or anyone applying with you have earned income?
Yes
No If yes, provide
information below:
Income Details
Name of person
Name of person
working
working
Employer
Employer
____
Last worked/paid
____
Pay frequency
Hourly wage
Hourly wage
____
Work schedule
$
$
Hours worked per week
Hours worked per week
Self-employment
Self-employment
____Leave job or
$
/month
$
/month
reduce
hours in last 30 days
20. Do you or anyone applying with you have any of the following expenses? (Expenses must
be reported and verified by your household to receive a deduction)
Child Support
Child Care
Alimony
Medical Expenses
___Medicare Rx card
None
____Subsidy amount
Total Expenses $________________per month
21. Please list housing expenses for you or anyone applying with you:
nd
2
Rent $
Mortgage
$
$
Lot Space
$
Mortgage
Taxes (yearly
Insurance
____How meet
$
$
Other
$
amount)
(yearly amount)
expenses
____Homeless
Subsidized Housing
Yes
No
22. Do you have heating and/or cooling expenses that are separate from your rent and/or
mortgage payment?………………………………………………………………………
Yes
No
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