Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 6
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2921. In the past year, did anyone in your household change jobs, stop working
or start working fewer hours? …………………………………………………...
Yes
No
If yes, who? ________________ Explain change(s): _______________________________
22. Does anyone in your household receive the following types of educational
income? ..........................................................................................................
Yes
No
If yes, complete all columns:
Number of
Date
Recipient’s
D34314000240629
Amount
Type
Months Intended
Income
Name
Received
to Cover
Started
Montgomery GI Bill
Stipend - Living Expenses
Veterans Educational
Assistance/Dependent
Work Study (Not Title IV)
Are there any educational expenses? ............... ............................................................................
Yes
No
If yes, complete all columns. Some examples of educational expenses are tuition, books, mandatory fees,
transportation or the rental or purchase of equipment, materials and supplies.
Type
Amount
Who Pays This
How Often Paid
Date Expense Started
23. Does anyone in your household have any of the following types of income? .......................................
Yes
No
If yes, complete all columns:
How Often Paid
Amount
Date Income
Recipient’s Name
Type
(ex: weekly,
Received
Started
monthly)
Social Security
SSI
Child Support received directly from
parent or another state
Child Support received through ORS
Unemployment
State:
Money received from family, friends or
church
From who?
Retirement
Pension
Alimony
Veteran’s Benefits
Workers Compensation
Tribal Income
Lump Sum Payments
Other income
(Ex: Adoption, Mineral Rights,
Rental, Royalty, Child and Adult Care Food
: ______________
Program payments etc.)
Other than taxes, are any deductions being withheld from anyone’s income listed? …….............
Yes
No
If yes, complete the following information:
Name: _________________________ Type of deduction? _______________ Deduction amount: $___________
Name: _________________________ Type of deduction? _______________ Deduction amount: $___________
Page 6
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