Particpant Name(Required)
First (and Middle, optional)
Last
Family Advocate
First
Last
Earned Income Information Did anyone in your household earn money from Work/Employment or On-the-Job-Training?(Required) If Yes, complete below.
Person 1 Earned Income Earned Income
List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings Do you have an additional source of earned income? Do you have an additional INDIVIDUAL to add with earned income?
Person 1 Earned Income, 2nd Source List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings Do you have an additional source of earned income? Do you have an additional INDIVIDUAL to add with earned income?
Person 1 Earned Income, 3rd Source List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings Do you have an additional INDIVIDUAL to add with earned income?
Person 2 Earned Income Earned Income
List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings Do you have an additional source of earned income?
Person 2 Earned Income, 2nd Source List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings Do you have an additional source of earned income?
Person 2 Earned Income, 3rd Source List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.
Week 1 Earnings Week 2 Earnings Week 3 Earnings Week 4 Earnings Week 5 Earnings
Unearned Income Information Did anyone in your household receive unearned income?(Required) Unearned income includes: Child/spousal support; interest or dividends; gambling/lottery winnings; insurance or legal settlements; strike benefits; cash, gifts, loans, scholarships; tax refunds; any government benefits, like social security, SSI, SSP, unemployment, worker’s compensation, retirement; rental income and rental assistance, free housing/utilities/clothing/food, per capita, foster care, adoption support; or anything else. If Yes, complete below.
Unearned Income (click the + at the end of the row to report additional instances)
Personal Information Does anyone in your household have any changes to report in the last 30 days?(Required)
Household Change Information Check ALL household changes in the last 30 days and attach proof. Explain ALL Other household changes:
List Household Change Information Who moved in/out? Explain ALL Other changes to household composition:
List Household Composition Information Have you physically moved or have a new mailing address?(Required) New Physical Address
New Mailing Address (if different)
School Enrollment information Did any Adult or Child enroll in school, stop or get expelled from school?(Required) List who and attach proof if applicable.
List School Information
Background Information Has anyone in your household been charged with or convicted of a felony?(Required) List Background Information Has anyone been arrested for or been involved in Domestic Violence in the past month?(Required) Is there anything else to report?(Required) Additional Information to Report
Certification Certification(Required) I must contact my Family Advocate within 5 days of any changes in my household that may affect my eligibility for the amount of my cash assistance.
Certification(Required) Facts I report may result in an increase, decrease, or termination of cash assistance.
Certification(Required) Cash assistance maybe delayed or terminated because of an incomplete or late MER.
Certification(Required) It is considered fraud if I knowingly and purposely give false facts about my income, property or family status to continue receiving benefits or cash assistance.