Form Fa-001 - Application For Benefits Page 19

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Tell us about other income everyone receives. You may need to provide proof of income.
Other Income:
Who
How often
Who pays the
Type of Income:
Amount
Receives?
received?
income?
Is anyone in the household an owner or member of a
franchise, corporation or limited liability corporation?
Social Security Benefits
Supplemental Security Income (SSI Cash)
Retirement/pension
Unemployment
Disability/worker’s compensation
Child Support  Court Ordered  Other _____________
Spousal Maintenance (Alimony)
Veterans benefits
Gifts, contributions or loans
Tribal money
 Gaming
 Other: __________
Rental income
Per capita payments from natural resources, usage rights,
leases or royalties
Payments from natural resources, farming, ranching, fishing,
leases or royalties from Indian trust land
Money from selling things that have cultural significance
Other: ________________________________________
Check here if no other income
Expected Income Changes:
 Yes  No
If Yes, who? __________________________
In the next twelve (12) months, does anyone in the household expect
How many sources are expected to change? _____________
income changes because of seasonal work or contract employment? Please
Name of sources ___________________________________
tell us only about the changes that happen regularly.
Amount expected to make in the next 12 months
$________________________________________________
 Yes  No
If Yes, who?____________________________________
Does anyone in the household expect changes in income for any other reason
Please explain:
in the next twelve (12) months?
Tell us if anyone has the following expenses that can be taken for
Allowed deductions from taxes/income:
taxes. Do not include self-employment expenses.
Expense
Who has the expense?
Amount
How Often?
Deductions from pay for expenses like retirement and insurance
taken out before taxes
Student Loan Interest
Spousal Maintenance (Alimony)
Other (Type) ________________________________________
Page 10
FA-001 (12-17)

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