Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 5
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2914. This question is not required for Food Stamps:
Has anyone in your household applied for, received, or been denied Social Security Income,
Veterans Benefits, Unemployment or Workers’ Compensation? ...................
Yes
No
If yes, who? ______________________ Benefit type: ________________________
15. This question is not required for medical assistance:
Is anyone in your household a fleeing felon? (Hiding or running from the law to avoid
prosecution, being taken into custody, or going to jail, for a felony crime or attempted felony
D34314000240529
crime) .............................................................................................................
Yes
No
If yes, who? _____________________________________________________________
16. This question is not required for medical assistance:
Is anyone in your household violating a condition of parole or probation for a felony
or misdemeanor?............................................................................................
Yes
No
If yes, who? _____________________________________________________________
INCOME
17. Does anyone in your household have earned income? .......................................................................
Yes
No
If yes, complete all columns:
Hourly Rate
Additional
How Often
Hours
or Monthly
Employed
Employer
Date of
Income
Paid
Worked
Salary
Person
Name
Hire
(ex: Tips, Bonus,
(ex: weekly,
Weekly
(ex: $900/mo,
Commission)
monthly)
$8/hr)
18. Is anyone in your household self-employed? .......................................................................................
Yes
No
If yes, complete all columns:
Hours
Type of Business
Business
Gross Monthly
Self - Employed Person
Company Name
% Owned
Worked
(ex: LLC, S-Corp,
Start Date
Income
Monthly
1099, etc.)
Are there any self-employment expenses? ....................................................................................
Yes
No
Answering this question is only required for medical assistance: How much net income (profits
once business expenses are paid) will you get from this self-employment this month? _______________________
19. Does anyone in your household expect any changes in earnings or in the number of hours worked?
Yes
No
If yes, who? ___________________ Explain change(s):________________________________________
20. Has anyone in your household left a job or reduced work hours in the last 30 days? ..........................
Yes
No
If yes, complete the following information:
If left a job:
Name:
Name of employer:
Last day worked:
Date of last pay check:
Reason the job ended:
If reduced work hours:
Name:
Name of employer:
Hours reduced from:
to:
Date of first pay check with reduced hours:
Reason hours reduced:
Page 5
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