Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance (Page 3 of 4) in pdf

Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance Page 3

Please list each individual who is living at the residence address. If someone in the household is not a U.S. citizen and wants to receive assistance, please enter

that person’s alien registration number. If the person has a sponsor, list that person's sponsor and the sponsor's spouse. You do not have to provide a social security

number for someone who is not applying for cash, medicaid or food stamps. If you are applying for cash or medical benefits under the refugee resettlement

program, you do not need to provide a social security number to receive these benefits. If you need more space, attach a separate piece of paper.

FIRST

MIDDLE

LAST

SOCIAL

PREGNANT

“U.S. CITIZEN” OR “NON-

DATE OF

SEX*

RACE*

ETHNICITY

BOARDER

NAME

INITIAL

NAME

SECURITY

YES/NO

CITIZEN” AND ALIEN

BIRTH

M/F

YES/NO

NUMBER*

REGISTRATION NUMBER

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

U.S. CITIZEN 9

NON-CITIZEN 9 #

* Title VI of the Civil Rights Act of 1964 allows us to ask for racial/ethnic information. You do not have to give us racial/ethnic information. If you do not

want to give us this information, it will have no effect on your case. If you do not give us this information, the worker will enter an answer. If your

household is only applying for food stamps, you do not have to complete the gender (sex) or pregnant box.

For race, please use the following code(s) - Select one or more:

For ethnicity, please use the following codes:

American Indian or Alaska Native

(D)

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

(A)

(1)

Asian

(E)

White

Not Hispanic or Latino

(B)

(2)

Black or African American

(C)

Since January 1, 1990, has the person for whom this application is being completed, or their spouse, resided in a nursing home, or been hospitalized for at least 30

9 9 Yes 9 9 No

consecutive days?

If yes, who?

9 9 Yes 9 9 No

Has anyone in the household ever received cash, Medicaid or food stamps in another state?

If yes, who?

When? (Years)

Where? (City/County/State)

JFS 07200 (Rev. 07/2002)

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