HOUSEHOLD COMPOSITION: PLEASE PRINT List all persons who will be residing in this household, even those completing their own application Person with Lives in Member Relation Date of Birth Veteran Percentage Name(s) Gender SSN Disabilities Household # to Head MM/DD/YY (Y/N) of Time (Y/N) 100% (Y/N) 1 Head 2 3 4 5 6 Anticipated changes in household size? (Y/N) ______ If yes, please explain_____________________________________________________________________ EDUCATION INFORMATION: PLEASE PRINT LIST ALL HOUSEHOLD MEMBERS. Keep the Member # the same as listed above. Note: Questions about disability are voluntary and are for the sole purpose of determining eligible student status Full Time or Last Year of Member Currently a Last Grade Type of School (Pre-K, Part Time School Name of School # Student (Y/N) Level elementary, college, etc.) Student (F/P) Completed 1 2 3 4 5 6 Anticipated change in number of students (Y/N) _____, if yes, please explain_____________________________________________________________________ VEHICLES (including company cars, motorcycles, etc.) Member # Driver’s License Number State Model Year Color License Plate Number State Monthly Payment
HOUSEHOLD COMPOSITION: PLEASE PRINT List all persons who will be residing in this household, even those completing their own application Member # Name(s) Relation to Head Gender Date of Birth MM/DD/YY SSN Person with Disabilities (Y/N) Veteran (Y/N) Lives in Household 100% (Y/N) Percentage of Time 1 Head 2 3 4 5 6 Anticipated changes in household size? (Y/N) ______ If yes, please explain_____________________________________________________________________ EDUCATION INFORMATION: PLEASE PRINT LIST ALL HOUSEHOLD MEMBERS. Keep the Member # the same as listed above. Note: Questions about disability are voluntary and are for the sole purpose of determining eligible student status Member # Currently a Student (Y/N) Last Grade Level Full Time or Part Time Student (F/P) Last Year of School Completed Name of School Type of School (Pre-K, elementary, college, etc.) 1 2 3 4 5 6 Anticipated change in number of students (Y/N) _____, if yes, please explain_____________________________________________________________________ VEHICLES (including company cars, motorcycles, etc.) Member # Driver’s License Number State Model Year Color License Plate Number State Monthly Payment
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