Form Step 8 - Supportive Transitional Emancipation Program Transitional Independent Living Plan Page 7

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PERSONAL DATA FORM
These questions are for data collection purposes only.
Your answers do not affect your eligibility for STEP and you are not required to answer the questions in order to receive STEP.
1.
Current Marital Status:
Never Married
Married
Widowed
Divorced
Legally Separated
2.
Number of children:
0
1
2
3
4
5
3.
Since I turned 18 years old I was incarcerated:
YES
NO
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-679) and the information Practices Act of 1977 (Civil Code Sections 1798, et. seq.),
notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The
principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the
requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under
Article 6, Section 1798.17 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all
personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information
maintenance to your IPA Forms Officer.
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