Phone Number Supervisor’s Name Street Address: City, State, Zip Hours worked ___ per week or ___ per month Pay rate Spouse’s Employer Street Address: City, State Zip Hours worked ___ per week or ___ per month Pay rate If unemployed, list: Length of time unemployed Name of previous employer Street Address of previous employer: City, State, Zip Financial Information of the Child’s Parent(s) or Other Person Responsible for the Welfare of the Child Public Assistance Income (Monthly) Monthly Are you currently receiving Amount all that apply) Take Home Pay ___ Food Stamps Spouse’s Take Home Pay ___ Medicaid Investment Income ___ Public housing Dividend ___ Temporary Assistance to Bond Dividend Needy Families (TANF) Rental Income ___ Supplemental Security Pension Payments Income (SSI) Unemployment Social Expenses (Monthly) Security Benefits Child Support Public Assistance TANF SSI Medicaid Other Cash Other Monthly (Describe) Payment Rent or Mortgage Payment Car Payment TOTAL Insurance (Life, Health, Car, Homeowners, etc.) GROSS Child Care MONTHLY Support INCOME Water Gas Telephone Electricity Food Clothes Medical Cable TV or Satellite TV Pager Cell Phone Loan and Debt Payments Outstanding Loans (list type of Loans)
Phone Number Supervisor’s Name Street Address: City, State, Zip Hours worked ___ per week or ___ per month Pay rate Spouse’s Employer Street Address: City, State Zip Hours worked ___ per week or ___ per month Pay rate If unemployed, list: Length of time unemployed Name of previous employer Street Address of previous employer: City, State, Zip Financial Information of the Child’s Parent(s) or Other Person Responsible for the Welfare of the Child Public Assistance Are you currently receiving all that apply) ___ Food Stamps ___ Medicaid ___ Public housing ___ Temporary Assistance to Needy Families (TANF) ___ Supplemental Security Income (SSI) Income (Monthly) Monthly Amount Take Home Pay Spouse’s Take Home Pay Investment Income Dividend Bond Dividend Rental Income Pension Payments Unemployment Social Security Benefits Child Support Public Assistance TANF SSI Medicaid Other Cash Other (Describe) TOTAL GROSS MONTHLY INCOME Expenses (Monthly) Monthly Payment Rent or Mortgage Payment Car Payment Insurance (Life, Health, Car, Homeowners, etc.) Child Care Support Water Gas Telephone Electricity Food Clothes Medical Cable TV or Satellite TV Pager Cell Phone Loan and Debt Payments Outstanding Loans (list type of Loans)
Andrews%20Juvenile%20Board%20Affidavit%20of%20Indigence.docx