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Male
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Female
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Male
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Female
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Male
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Female
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Own
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Own
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Own
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Buying
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Renting
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Renting
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Renting
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Homeless
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Homeless
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Homeless
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Other
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Other
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Other
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Buying
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Buying
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Married
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Married
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Married
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Single
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Single
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Single
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Divorced
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Divorced
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Divorced
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Separated
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Separated
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Separated
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Widowed
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Widowed
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Widowed
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*
Yourself
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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Child
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Spouse
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Relative
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Room Mate
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Other Adult
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*
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Type
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Draw
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*
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Draw
Type
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*
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*
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Draw
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*
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*
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Draw
Type
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Yes
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No
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Wages Stopped
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Wages Stopped
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Wages Stopped
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Waiting on Income
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Waiting on Income
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Waiting on Income
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Receiving Income
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Receiving Income
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Receiving Income
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No Income
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No Income
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No Income
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Currently Working
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Currently Working
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Currently Working
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Laid Off
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Laid Off
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Laid Off
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Never Worked
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Never Worked
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Never Worked
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Quit
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Quit
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Quit
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Fired
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Fired
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Fired
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Sick Leave
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Sick Leave
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Sick Leave
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Maternity Leave
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Maternity Leave
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Maternity Leave
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On Strike
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On Strike
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On Strike
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Trying to Find Work
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Trying to Find Work
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Trying to Find Work
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Life Insurance - Yes
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Life Insurance - No
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Life Insurance - Yes
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Life Insurance - No
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Life Insurance - Yes
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Life Insurance - No
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Other Insurance - Yes
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Other Insurance - No
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Other Insurance - Yes
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Other Insurance - No
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Other Insurance - Yes
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Other Insurance - No
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Investments - Yes
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Investments - No
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Investments - Yes
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Investments - No
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Investments - Yes
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Investments - No
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Cash on Hand - Yes
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Cash on Hand - No
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Cash on Hand - Yes
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Cash on Hand - No
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Cash on Hand - Yes
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Cash on Hand - No
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Checking Account - Yes
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Checking Account - No
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Checking Account - Yes
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Checking Account - No
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Checking Account - Yes
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Checking Account - No
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Savings Account - Yes
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Savings Account - No
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Savings Account - Yes
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Savings Account - No
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Savings Account - Yes
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Savings Account - No
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*
*
*
*
*
*
Claims Against Others - Yes
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Claims Against Others - No
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Own Property - Yes
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Own Property - No
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Other Adult 1 Own Property - Yes
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Other Adult 1 Own Property - No
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Other Adult 2 Own Property - Yes
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Other Adult 2 Own Property - No
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Related to Landlord - Yes
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Related to Landlord - No
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Utilities Included - Yes
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Utilities Included - No
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US Citizen - Yes
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US Citizen - No
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Child Support Ordered - Yes
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Child Support Ordered - No
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Will Go to Court - Yes
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Will Go to Court - No
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Receiving Child Support - Yes
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Receiving Child Support - No
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*
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Other Help - Yes
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Other Help - No
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Bills in Someone Else's Name - Yes
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Bills in Someone Else's Name - No
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*
No Income
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Not Enough Income
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Income Stolen
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Emergency Event
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Emergency Circumstance - Yes
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Emergency Circumstance - No
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*
*
*
*
*
*
Subsidized Housing - Yes
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Subsidized Housing - No
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Other Adult Subsidized Housing - Yes
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Other Adult Subsidized Housing - No
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Other Adult 2 Subsidized Housing - Yes
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Other Adult 2 Subsidized Housing - No
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Utility Allotment - Yes
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Utility Allotment - No
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Other Adult Utility Allotment - Yes
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Other Adult Utility Allotment - No
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Other Adult 2 Utility Allotment - Yes
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Other Adult 2 Utility Allotment - No
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*
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Food Stamps - Yes
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Food Stamps - No
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Other Adult Food Stamps - Yes
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Other Adult Food Stamps - No
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Other Adult 2 Food Stamps - Yes
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Other Adult 2 Food Stamps - No
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*
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AFDC Welfare - Yes
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AFDC Welfare - No
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Other Adult AFDC Welfare - Yes
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Other Adult AFDC Welfare - No
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Other Adult 2 AFDC Welfare - Yes
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Other Adult 2 AFDC Welfare - No
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*
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Other Trustee Office - Yes
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Other Trustee Office - No
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Other Adult Other Trustee Office - Yes
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Other Adult Other Trustee Office - No
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Other Adult 2 Other Trustee Office - Yes
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Other Adult 2 Other Trustee Office - No
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Social Security - Yes
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Social Security - No
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Other Adult Social Security - Yes
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Other Adult Social Security - No
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Other Adult 2 Social Security - Yes
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Other Adult 2 Social Security - No
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VA Benefits - Yes
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VA Benefits - No
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Other Adult VA Benefits - Yes
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Other Adult VA Benefits - No
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Other Adult 2 VA Benefits - Yes
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Other Adult 2 VA Benefits - No
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EAP Utility Assistance - Yes
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EAP Utility Assistance - No
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Other Adult EAP Utility Assistance - Yes
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Other Adult EAP Utility Assistance - No
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Other Adult 2 EAP Utility Assistance - Yes
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Other Adult 2 EAP Utility Assistance - No
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FEMA Funds - Yes
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FEMA Funds - No
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Other Adult FEMA Funds - Yes
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Other Adult FEMA Funds - No
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Other Adult 2 FEMA Funds - Yes
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Other Adult 2 FEMA Funds - No
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Unemployment Benefits - Yes
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Unemployment Benefits - No
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Other Adult Unemployment Benefits - Yes
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Other Adult Unemployment Benefits - No
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Other Adult 2 Unemployment Benefits - Yes
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Other Adult 2 Unemployment Benefits - No
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Grants Loans - Yes
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Grants Loans - No
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Other Adult Grants Loans - Yes
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Other Adult Grants Loans - No
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Other Adult 2 Grants Loans - Yes
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Other Adult 2 Grants Loans - No
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*
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Other Help - Yes
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Other Help - No
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Other Adult Other Help - Yes
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Other Adult Other Help - No
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Other Adult 2 Other Help - Yes
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Other Adult 2 Other Help - No
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YES
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NO
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AFDC Terminated - Yes
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AFDC Terminated - No
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Welfare Fraud - Yes
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Welfare Fraud - No
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*
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Applicant Signature - Yes
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Applicant Signature - No
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Other Adult Signature - Yes
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Other Adult Signature - No
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Other Adult 2 Signature - Yes
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Other Adult 2 Signature - No
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*
*
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