Form Fa-001 - Application For Benefits Page 18
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Tell us about everyone applying to help determine if he/she may be eligible for additional benefits
Potential Benefits:
.
Has anyone you are applying for, their spouse or deceased
spouse, worked for:
If Yes, who? __________________________________
Yes
No
Employer name: _____________________________
A government agency
Dates of employment: __________________________
An employer with a pension plan?
If Yes, provide the following information:
Is anyone you are applying for:
Veteran’s Name:_______________________________
A person who served in the U.S military,
Veteran’s Social Security
The spouse of a person who served in the U.S. military,
Yes
No
Number: ____________________________________
The widow or widower of a person who served in the
Service Serial Number:________________________
U.S. military, or
Branch of service:______________________________
The child of a person who served in the U.S. military?
Veteran’s Date of Birth:________________________
VA Claim Number:_____________________________
Dates of service: ____________________________
Answer the following questions if anyone in your household is applying for Nutrition Assistance and/or
Expenses:
Cash Assistance.
Do you or anyone in your household pay for the care of a child
If Yes, amount: $ ______________________________
Yes
No
or disabled adult in order to work, look for work, attend training o
school?
Do you or anyone in your household have transportation
Yes
No
If Yes, amount: $ ______________________________
costs to travel to/from the person or agency that provides after
school care or adult daycare?
Do you or anyone in your household pay court-ordered child
Yes
No
If Yes, who pays? _____________________________
support?
Amount paid: $ _______________________________
How often paid? ______________________________
Tell us about everyone’s employment, including self-employment and rental income. You may
Employment:
need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE and
applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business
income and expenses for at least the last and current calendar month.
Does ANYONE work?
Yes
No
If Yes, give employment information below:
Gross Earnings Per Pay
How many hours
How often paid?
Employer’s Name and
Who
check and date
worked
Weekly, Biweekly,
Phone Number:
Semi Monthly, Monthly
(before deductions):
per week?
Did anyone leave a job in the last thirty (30)
Yes
No
If Yes, who?_______________________________________________
days?
If Yes, who?_______________________________________________
Yes
No
Is ANYONE self-employed?
Type of work: ______________________________________________
Annual gross income (before business expenses): $________________
Annual business expenses: $ _________________________________
Has business been in existence for 12
If No, date business started: __________________________________
Yes
No
months?
If Yes, who?______________________________________________ _
Yes
No
Type of work: _____________________________________________
Is more than one person self-employed?
Annual gross income (before business expenses): $______________ _
Annual business expenses: $ ________________________________
Yes
No
If No, date business started: _________________________________
Has business been in existence for 12 months?
FA-001 (12-17)
Page
9
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