Household Income Does the household have any current income? Yes No Client Does Not Know Client Refused     If No, answer the following question and move on to Household Income for AMI Below: Do you need assistance in applying for cash benefits?   Yes No If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. HH Member Amount Start Date HH Member Amount Start Date Earned Income $ $  Yes No If Yes: $ $ Social Security Disability Income  Yes No If Yes: $ $ Worker’s Compensation  If Yes: $ $ Yes No Child Support  If Yes: $ $ Yes No Retirement Income from Social Security  If Yes: $ $ Yes No Unemployment Insurance  If Yes: $ $ Yes No VA Service Connected  Yes No If Yes: $ $ VA Non-Service Connected  If Yes: $ $ Yes No Alimony or Other Spousal Support  If Yes: $ $ Yes No Temporary Assistance for Families (TANF)  Yes No If Yes: $ $ SSI: Supplemental Security Income  If Yes: $ $ Yes No Private Disability Insurance  Yes No If Yes: $ $ General Assistance  If Yes: $ $ Yes No Pension from a former job  If Yes: $ $ Yes No Source (specify):  Yes No If Yes: $ $ For Each Individual Household Member with income, record their individual total income from all sources below Household Member Monthly Income Household Member Total Monthly Income
Household Income Does the household have any current income?  Yes  No  Client Does Not Know  Client Refused If No, answer the following question and move on to Household Income for AMI Below: Do you need assistance in applying for cash benefits?  Yes  No If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. HH Member Amount Start Date HH Member Amount Start Date Earned Income  Yes No If Yes: $ $ $ $ Social Security Disability Income  Yes No If Yes: $ $ Worker’s Compensation  Yes No If Yes: $ $ Child Support  Yes No If Yes: $ $ Retirement Income from Social Security  Yes No If Yes: $ $ Unemployment Insurance  Yes No If Yes: $ $ VA Service Connected  Yes No If Yes: $ $ VA Non-Service Connected  Yes No If Yes: $ $ Alimony or Other Spousal Support  Yes No If Yes: $ $ Temporary Assistance for Families (TANF)  Yes No If Yes: $ $ SSI: Supplemental Security Income  Yes No If Yes: $ $ Private Disability Insurance  Yes No If Yes: $ $ General Assistance  Yes No If Yes: $ $ Pension from a former job  Yes No If Yes: $ $ Source (specify):  Yes No If Yes: $ $ For Each Individual Household Member with income, record their individual total income from all sources below Household Member Monthly Income Household Member Total Monthly Income