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Household Income

Include as income: gross wages, net self-employment income, alimony, Social security benefits, rental property income, pensions, dividends, interest on savings, training stipends, grants (excluding Pell Grants), railroad retirement benefits, strike benefits, net gambling or lottery winnings.
Do NOT include as income: any form of public assistance, Supplemental Security income, unemployment compensation, child support received, loans, one-time gifts, lump-sum inheritances, withdrawals from savings account, tax refunds, one-time insurance payments or compensation for injury, payments made on behalf of a foster child, the sale of property, HUD rental assistance programs.

Including yourself, how many people, related to you by blood, marriage, or adoption have lived in the same household in the past 6 months?

What was your income (for only the applicant) for the last year? If nothing enter "0":

Annual Income from other Family Members (enter 0 if applicant is the only person in the household):

	Name	Annual Income
For each member of the household, who has income, write their name and income.

If you are eligible for the program, what time frame is best for you to attend an information and paperwork session? Sessions are held during the week (Monday through Friday) and generally last 2 hours. You will need to be in attendance for the entire session time.

Morning (10-12)Afternoon (1-3)Late Afternoon (2:30-4:30)Evening (5-7)Select all that apply

Type your name here to attest that you have read, understood, and agree with all of the information and statements within this application.

Contact Information