INCOME FROM ANY SOURCE of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY “YES” – Income Source Amount Income Source Amount Alimony and other spousal support Child support ○ ○ Pension or retirement income from former job Earned Income ○ ○ Retirement Income from Social Security General Assistance (GA) ○ ○ Social Security Disability Insurance (SSDI) Private disability insurance ○ ○ Supplemental Security Income (SSI) Unemployment Insurance ○ ○ TANF (Temporary Assist for Needy Families) Worker’s Compensation ○ ○ VA Service Connected Disability Compensation Other source ○ ○ Other (specify): VA Connected Disability Pension ○ Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO BENEFITS INDICATE ALL SOURCES THAT APPLY “YES” – ○ Supplemental Nutrition Assistance Program (SNAP) TANF Childcare Services ○ Special Supplemental Nutrition Program for Women, ○ TANF Transportation Services ○ Infants, and Children (WIC) ○ (Specify): Other TANF-funded services ○ COVERED BY HEALTH INSURANCE Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS “YES” MEDICAID Employer Provided Health Insurance ○ ○ MEDICARE Insurance Obtained through COBRA ○ ○ Children’s Health Insurance (SCHIP) Private Pay Health Insurance ○ ○ Veteran’s Administration (VA) Medical Services State Health Insurance for Adults ○ ○ (specify) Indian Health Services Program ○ ○
INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source Amount ○ Alimony and other spousal support ○ Child support ○ Pension or retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA) ○ Social Security Disability Insurance (SSDI) ○ Private disability insurance ○ Supplemental Security Income (SSI) ○ Unemployment Insurance ○ TANF (Temporary Assist for Needy Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Other (specify): Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO BENEFITS – INDICATE ALL SOURCES THAT APPLY ○ Supplemental Nutrition Assistance Program (SNAP) ○ TANF Childcare Services ○ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) ○ TANF Transportation Services ○ (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health Insurance ○ MEDICARE ○ Insurance Obtained through COBRA ○ Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ (specify) ○ Indian Health Services Program