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Income Income from Work (before taxes or other deductions: gross, not net amount) Are you or is anyone in your house working? �� Yes �� No Person who is working Employer’s Name/Telephone Start Date How much is each paycheck? (before taxes) How often do you get paid? (weekly, biweekly, monthly, etc.) $ (GROSS) $ (GROSS) Other Income Do you or anyone else get any other income? Please check all that apply and list each payment below. �� SSI �� Unemployment/Workers Comp. �� Child support �� Social Security (not SSI) �� Pensions and retirement �� Help with expenses �� Veterans benefits �� Foster care/adoption subsidy �� Other ______________ Type of Payment Who gets this? How much is each payment? (before taxes and deductions) How often do they get this? (weekly, biweekly, monthly, etc.) $ (GROSS) $ (GROSS) Does anyone pay your family for meals or to rent a room (for example, ar oommate or boarder)? �� Ye s �� No If YES, who pays? ____________ How much do they pay each month? $ _____________ Assets Cas h Does anyone have more than $1,000 in cash? If YES, how much $ _________ �� Yes �� No Bank Accoun ts Does anyone have more than $1,000 in the bank? If YES, please attach your most recent bank statement(s). �� Yes �� No Life Insuranc e Does anyone have life insurance that they can cash in? If YES, how much money would you get if you cashed it in today? $ ____________ �� Yes �� No Real Proper ty Does anyone own property besides the home you live in? (For example: boats, rental property, real estate) �� Yes* �� No C ar Does anyone own a car, truck or van? If YES, list Make, Model and Year below. _________________________________ Is it used by someone who’s sick/disabled? �� Yes �� No �� Yes �� No Oth er Does anyone have any stock, bonds, etc.? �� Yes* �� No Transfe rs Did anyone sell, trade, or give away anything worth more than $1,000 during the last three (3) years? �� Yes* �� No * If YES, please attach a description to this for m . 3 of 8 Decembe r 2015


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