Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance (Page 2 of 4) in pdf

Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance Page 2

FOR THE FOLLOWING QUESTIONS , “HOUSEHOLD MEMBERS” INCLUDES YOURSELF AND ALL THE PEOPLE WHO LIVE WITH YOU, BUY

FOOD WITH YOU AND WHO FIX MEALS WITH YOU.

Is your household's net monthly income zero (either prior to or after allowable adjustments) and your household's total liquid resources, such as cash, checking or savings

accounts, $100 or less? 9 9 Yes 9 9 No

Is your household's total gross monthly income less than $150 and your household's total liquid resources, such as cash, checking or savings accounts, $100 or less?

9 9 Yes 9 9 No

9 9 No

Is your household's monthly rent or mortgage and utilities more than your household's total monthly gross income and total liquid resources? 9 9 Yes

9 9 No

9 9 Yes

Is your household a migrant or seasonal farm working household with little or no income and total liquid resources of $100 or less?

How many people live in your home and eat with you? (Include yourself)

9 9 Yes 9 9 No

If yes, who? ________________________Employer's name:

Is anyone in your household on strike?

Did your household's only income recently stop? 9 9 Yes 9 9 No

If yes, when?

9 9 Yes 9 9 No

9 9 Don’t Know

If yes, how much?

Does anyone in your household expect to receive income later this month?

From what source?

9 9 Yes 9 9 No

Is anyone in your household 60 years of age or older?

Is anyone in your household receiving Supplemental Security Income (SSI) benefits, Social Security Disability payments, or Veterans' benefits because of a disability?

9 9 Yes 9 9 No

If yes, is this person unable to prepare meals due to disability?

If you answered "Yes" to all of the last three questions, does this person (and spouse) wish to receive food stamps separately from other members of the household?

9 9 Yes 9 9 No

How much do the members of your household have in cash and savings? (Give your best estimate of the total.)

9 9 Yes 9 9 No If yes, what is the gross amount? $

Has anyone in your household received any income so far this month?

From what source?

9 9 Yes 9 9 No If yes, who?

Did any household member leave a job within the last 60 days?

If yes, why?

How much do you pay per month for rent or mortgage, plus utilities? $

JFS 07200 (Rev. 07/2002)

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