Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 9
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29FINANCIAL ASSISTANCE SECTION
34. Has anyone in your household been disqualified in any state from the TANF (Financial)
program for a program violation? ...................................................................
Yes
No
If yes, who? ________________________________ State: ________________________
35. Has anyone in your household received out-of-state TANF months? ………
Yes
No
If yes, who? __________ State(s):___________________ Number of months: _________
D34314000240929
36. Are any children in your household home-schooled? ....................................
Yes
No
If yes, who? _________________ Is this school district approved? .........
Yes
No
37. Do you have rent that is subsidized by any federal, state, or local government
agency, including a private social service agency? ......................................
Yes
No
If yes, select one:
Public Housing Agency
Other Agency
38. Is anyone in your household a Veteran? ……………………………………………………..…………...
Yes
No
If yes, who? ___________________________________________________________________
39. Do you have child(ren) living in the home? ..........................................................................................
Yes
No
If yes, are you willing to cooperate with the Office of Recovery Services (ORS) regarding
establishment or collection of Child Support from an absent parent? ...........................................
Yes
No
List the name of the absent parent(s) and the name of the child(ren) of the absent parent.
Absent Parent Name: __________________________ Child(ren) of Absent Parent: ________________________
Reason for Absence:
Single Parent Adoption
Divorced
Separated
Legally Separated
Death
Incarceration
Other: ______________________________________
Absent Parent Name: __________________________ Child(ren) of Absent Parent: ________________________
Reason for Absence:
Single Parent Adoption
Divorced
Separated
Legally Separated
Death
Incarceration
Other: _____________________________________
CHILD CARE SECTION
40. Has anyone in your household been disqualified in any state from the Child Care program for a
program violation? ..............................................................................................................................
Yes
No
If yes, who? _________________________________________ State: ____________________
41. Does anyone in your household pay any of the following expenses? .................................................
Yes
No
If yes, complete all columns:
Person Paying
Amount
How Often
Date This
Type
Who For?
This
Paid
Paid?
Started
Court-Ordered Alimony
Court-Ordered Child Support
42. List the parents’ work schedule. Enter the time you start and end on each day for your most recent work schedule, even
if your schedule varies.
(ex: Mon 8:00 a.m. to 5:00 p.m.)
Name
Employer
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Is child care needed for all of the time you work? ...…..………………..........................................
Yes
No
If no, what day(s) and time is care needed? _________________________________________________
43. Is any parent in school or training? ......................................................................................................
Yes
No
If yes, enter the time you start and end on each day you attend class. (ex: Mon 8:00 a.m. to 5:00 p.m.)
School
Type of degree
Name
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Name
or certificate
Is child care needed for all of the time you attend training? .........................................................
Yes
No
If no, what day(s) and time is care needed? _____________________________________________________
Page 9
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