Form Fa-001 - Application For Benefits Page 12

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Personal Information:
Tell us about each person in your household, starting with you. See page A for a definition of whom you must include.
If you are a representative, tell us about who you are representing and others in the household.
Applying for?
Relationship to
Marital Status
Date
Social Security
Sex
Main Contact (1.)
(legally
of
Number
(Male
(spouse, child/step
Birth
(If not applying,
or
married,
child, parent,
optional)
Female)
common law
grandchild, niece/
marriage,
nephew, legal
Name
separated,
guardian, other
Last, First M.I.
divorced,
(
please describe)
widowed,
(Include Maiden, Alias,
never
Suffix and other names)
married,
unmarried
partner)
1.
Main Contact
2.
3.
4.
5.
6.
Complete ONLY for each person applying. If a person is not applying for benefits, skip this
Citizenship:
section for that person. For those applying, you may need to provide proof of citizenship.
Is the MAIN CONTACT a U.S. citizen or U.S. national? See page D for more information.
 Yes  No
 Choose not to answer
If the MAIN CONTACT is NOT a U.S. citizen, what is his/her immigration status?
 Lawful Permanent Resident (LPR)
 Battered Spouse, Child or Parent
 Removal/Suspension of Deportation
 Lawful Temporary Resident
 Cuban-Haitian Entrant
 Registry Applicants
 Non-Immigrant Status
 Deferred Action Status
 Special Immigrant Juvenile Status Applicant
 Asylee
 Deferred Enforced Departure
 Temporary Protection Status (TPS)
 Refugee
 Legalization under LIFE Act
 Victim of Trafficking
 Conditional Entrant granted before 1980
 Legalization under IRCA Applicant
 Withholding of Deportation
 Other
 Order of Supervision
 Applicant for Asylum, LPR, TPS, or
 I do not want to provide
 Paroled into United States
Withholding Deportation
What immigration document does MAIN CONTACT have?
Immigration Document Number: ________________________________
 Permanent Resident card
 I-94
 Visa
Has MAIN CONTACT lived in the U.S. since August 22, 1996?  Yes 
 Foreign Passport
 None
 Other: _________________________________
Is PERSON 2 a U.S. citizen or U.S. national? See page D for more information.
 Yes  No  Choose not to answer
If PERSON 2 is NOT a U.S. citizen, what is his/her immigration status?
 Lawful Permanent Resident (LPR)
 Battered Spouse, Child and Parent
 Removal/Suspension of Deportation
 Lawful Temporary Resident
 Cuban-Haitian Entrant
 Registry Applicants
 Non-Immigrant Status
 Deferred Action Status
 Special Immigrant Juvenile Status Applicant
 Asylee
 Deferred Enforced Departure
 Temporary Protection Status (TPS)
 Refugee
 Legalization under LIFE Act
 Victim of Trafficking
 Conditional Entrant Granted before 1980
 Legalization under IRCA Applicant
 Withholding of Deportation
 Other
 Order of Supervision
 Applicant for Asylum, LPR, TPS, or
 I do not want to provide
 Paroled into United States
Withholding Deportation
What immigration document does PERSON 2 have?
Immigration Document Number: ________________________________
 Permanent Resident card
 I-94
 Visa
Has PERSON 2 lived in the U.S. since August 22, 1996?  Yes  No
 Foreign Passport
 None
 Other: ________________________________
FA-001 (12-17)
Page
3

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