Form Fa-001 - Application For Benefits Page 14
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Tell us NEXT YEAR’S tax filing information for everyone applying
Federal Income Tax Filing:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Yes No
Main
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
Contact
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er) Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Yes No
Person
2
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Yes No
Person
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
3
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Yes No
Person
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
4
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Yes No
Person
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
5
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Plan to file Federal
Filing Status:
income tax return?
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
Person
Yes No
6
Will claim dependents on own tax return? Yes No
Claimed as dependent on someone else’s tax return?
If yes, list dependents’ names:
Yes No
If yes, name of tax filer claiming this person:
Tell us how your household buys and prepares food.
Food Preparation:
Does anyone at your address buy and prepare his/her own food separate from others in the household?
Yes
No
If Yes, tell us about the people who buy and prepare their own food:
Relationship to
Does this person
Name (First & Last):
Age:
What expenses?
MAIN CONTACT:
pay expenses?
Yes
No
Yes
No
Yes
No
Yes
No
FA-001 (12-17)
Page 5
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