A household member is any child or adult living with you.

Part 1: List all household members, the school name for each child, and the case number for any household member (including adults) those receiving SNAP or TANF benefits.

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

Part 1: List all household members and the school name for each child.

Part 2: Check the appropriate box.

Part 3: Skip this part.

Part 4: Complete only if a child in your household isn’t eligible under Part 2. See instructions for All Other Households.

Part 5: Sign the form. A Social Security Number is not necessary if you didn’t need to fill in Part 4.

Part 6: Answer this question if you choose to.

Part 1: Use a separate application for each foster child. List the child’s name, school, and, if the child has no income, check the box “no income.”

Part 2: Skip this part.

Part 3: Check the box and list the child’s personal use monthly income, if any.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

Part 1: List all household members and the school name for each child. For any person, including children, with no income, you must check the “No Income Box.”   

Part 2: Check the appropriate box, if any.

Part 3: Skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

·         Box 1–Name: List all household members with income.

·         Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly.  For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, and All Other Income sources. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. For ONLY the self-employed, under Earnings From Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

Part 5: Adult household member must sign the form and list Social Security Number (or mark the box if s/he doesn’t have one).

Part 6: Answer if you choose.