Employer Gross Annual Income Sources of Additional Income MARITAL / DOMESTIC PARTNER / CIVIL UNION INFORMATION Date of Current Marriage / Domestic Partnership / Civil Union PAST MARRIAGE(S) / DOMESTIC PARTNERSHIP(S) / CIVIL UNION(S) Date Begun Applicant 1 Full Name Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] Applicant 2 Full Name Date Begun Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] DATES OF CONTACT Date Person(s) Interviewed Length of Interview Location (Hours and Minutes) SONS AND DAUGHTERS OF APPLICANT(S) DOD, if Location and Living Situation Name Birthdate Age Receiving Care Deceased (Adult children must be interviewed. Provide contact information if not living in the home. Include date of death if deceased.) In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No In Home Yes Out of Home No OTHERS RESIDING OR FREQUENTLY IN THE HOME (INCLUDING OTHER PERSONS RECEIVING CARE) Foster children placed in the home or children placed in the pre-adoptive home are not included here. The definition of adults frequently in the home is any adult who is in the home on a regular basis and has substantial contact with children placed in the home or any adult who while in the home would have access to be alone with children placed in the home. Receiving Care Name Age Relationship Current Situation Yes
Employer Gross Annual Income Sources of Additional Income MARITAL / DOMESTIC PARTNER / CIVIL UNION INFORMATION Date of Current Marriage / Domestic Partnership / Civil Union PAST MARRIAGE(S) / DOMESTIC PARTNERSHIP(S) / CIVIL UNION(S) Applicant 1 Full Name Date Begun Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] Applicant 2 Full Name Date Begun Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] DATES OF CONTACT Date Person(s) Interviewed Length of Interview (Hours and Minutes) Location SONS AND DAUGHTERS OF APPLICANT(S) Name Birthdate Age DOD, if Deceased Location and Living Situation (Adult children must be interviewed. Provide contact information if not living in the home. Include date of death if deceased.) Receiving Care In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No OTHERS RESIDING OR FREQUENTLY IN THE HOME (INCLUDING OTHER PERSONS RECEIVING CARE) Foster children placed in the home or children placed in the pre-adoptive home are not included here. The definition of adults frequently in the home is any adult who is in the home on a regular basis and has substantial contact with children placed in the home or any adult who while in the home would have access to be alone with children placed in the home. Name Age Relationship Current Situation Receiving Care Yes
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