Are you currently employed? Yes □ □ If Yes, please name occupation: No If No, state reason Annual Household Income $25K $25K-$49,999 $50K-$69K $70K+ □under □ □ □ Head of Household Yes No Number in Household: □ □ List Sources of Income: Employment Child Support Public Assistance Family/friends provide support Social Security(Retirement) Pension Disability Unemployment Education Level: Some School High School Graduate Some College College Graduate □ □GED □ □ □ □
Are you currently employed? □ Yes □ No If Yes, please name occupation: If No, state reason Annual Household Income □under $25K □ $25K-$49,999 □ $50K-$69K □ $70K+ Head of Household □ Yes □ No Number in Household: List Sources of Income: Employment Child Support Public Assistance Family/friends provide support Social Security(Retirement) Pension Disability Unemployment Education Level: □ Some School □GED □ High School Graduate □ Some College □ College Graduate □