OCFS-5183B (4/2018) EMPLOYMENT HISTORY Employer: Dates of employment: / / To / / Position: Hours worked per week: Reason for leaving: Employer: Dates of employment: / / To / / Position: worked per week: Reason for leaving: Employer: Dates of employment: / / To / / Position: Hours worked per week: Reason for leaving: EDUCATION HISTORY Grade School High School GED Associates Degree HIGHEST EDUCATION COMPLETED: Bachelor’s Degree Master’s Degree Ph. D. Other: FINANCIAL INFORMATION (verified INCOME FROM EMPLOYMENT: by W-2 or 1040) PA SSI SSD Disability Child Support OTHER INCOME AND SOURCE: Other, specify: TOTAL MONTHLY INCOME: Expenses: rent/mortgage $ ► utilities $ ► car payments $ ► car insurance $ ► other insurance $ ► $ ► food, clothing, etc. $ ► Total monthly expenses $ For adoption only: Does your family have medical insurance coverage? No Yes Is your family experiencing any financial stressors (i.e. foreclosure, bankruptcy) etc.? No Yes If yes, please explain: SIGNATURE OF APPLICANT: DATE: X / /
OCFS-5183B (4/2018) EMPLOYMENT HISTORY Employer: Dates of employment: / / To / / Position: Hours worked per week: Reason for leaving: Employer: Dates of employment: / / To / / Position: worked per week: Reason for leaving: Employer: Dates of employment: / / To / / Position: Hours worked per week: Reason for leaving: EDUCATION HISTORY HIGHEST EDUCATION COMPLETED: Grade School High School GED Associates Degree Bachelor’s Degree Master’s Degree Ph. D. Other: FINANCIAL INFORMATION INCOME FROM EMPLOYMENT: (verified by W-2 or 1040) OTHER INCOME AND SOURCE: PA SSI SSD Disability Child Support Other, specify: TOTAL MONTHLY INCOME: Expenses: ► rent/mortgage $ ► utilities $ ► car payments $ ► car insurance $ ► other insurance $ ► $ ► food, clothing, etc. $ Total monthly expenses $ For adoption only: Does your family have medical insurance coverage? No Yes Is your family experiencing any financial stressors (i.e. foreclosure, bankruptcy) etc.? No Yes If yes, please explain: SIGNATURE OF APPLICANT: X DATE: / /