EmailMeForm
Additional Household Member
Coalfield CAP Weatherization Program
Today's Date
*
MM
/
DD
/
YYYY
Applicant name
*
First
Middle
Last
Whose name is the application under?
Additional household member name
*
First
Middle
Last
Relationship to Head of Household
*
Aunt
Brother
Custodial Parent
Daughter
Father
Former Spouse
Foster Child
Foster Parent
Grandchild
Grandparent
In-law
Mother
Nephew
Niece
Other
Partner
Sister
Son
Spouse
Stepchild
Uncle
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Other
Marital Status
Single
Divorced
Married
Separated
Partner
Widowed
Race
American Indian or Alaska Native
Asian
Bi-racial of Multi-racial
Black or African-American
Caucasian of White
Middle Eastern
Native Hawaiian or Pacific Islander
Unspecified
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Tribe
None
Blackfoot
Cherokee
Choctaw
Pawnee
Pima
Primary Language
African
Caribbean
Creole
East Asian
English
European/Slavic
German
Middle Eastern/South Asian
Native Central/South American or Mexican
North American/Alaska
Other
Pacific Island
Spanish
Health Insurance
Direct-Purchase
Employment Based
Medicaid
Medicare
Military Health Care
State Children's Health Insurance Program
State Health Insurance for Adults
None
Unknown
Education Level
0-8
9-12 Non-Graduate
High School Graduate/GED
Some College/Certificate/Trade
2-4 Year College Graduate
Post Graduate Degree
Unknown
Disabling Condition
Yes
No
Unknown
Military Status
Active Military
Veteran
None
Unknown
Characteristic (Check all that Apply)
Applicant
Debarred
Employee, Relative of Board Member
Youth (14-21) not working or in school
No Heat Emergency
Foster Child
Dwelling Type Override
Referred by DHHR
Vision Impaired
Hearing Impaired
Head Start / EHS - Foster Parent of Child
Head Start / EHS - Parent of Child
Head Start / EHS - Dual Custody Agreement
Head Start / EHS - Guardian of Child
Head Start / EHS - Over Income Exception
Head Start - Board of Edu. 4 yr old
Income
Monthly Income Sources for Household Member
No Financial Resources? (if yes No-Income Affidavit Required)
*
yes
No
Employment Earnings
$
Dollars
.
Cents
TANF
$
Dollars
.
Cents
SSI
$
Dollars
.
Cents
SSDI
$
Dollars
.
Cents
VA Service-Connected Disability Compensation
$
Dollars
.
Cents
VA Non-Service-Connected Disability Compensation
$
Dollars
.
Cents
Private Disability Insureance
$
Dollars
.
Cents
Worker's Compensation
$
Dollars
.
Cents
Retirement Income from Social Security
$
Dollars
.
Cents
Pension
$
Dollars
.
Cents
Child Support
$
Dollars
.
Cents
Alimony or other Spousal Support
$
Dollars
.
Cents
Unemployment Insurance
$
Dollars
.
Cents
EITC
$
Dollars
.
Cents
Other
$
Dollars
.
Cents
Non-Cash Benfits
SNAP
WIC
LIHEAP
Housing Choice Voucher
Public Housing
Permanent Supportive Housing
HUD-VASH
Childcare Voucher
Affordable Care Act Subsidy
Other
Total Monthly Income?
$
Dollars
.
Cents
Employment
Work Status
Is this person Employed?
Yes
No
Unknown
If Yes or No, what is her / his status
Employed Full-Time with benefits
Employed Full-Time without benefits
Employed Part-Time
Migrant Seasonal Farm Worker
Retired
Unemployed (Long-term more than 6 months)
Unemployed (Not in Labor Force)
Unemployed (Short-term 6 months or less)
Current Employer Name:
First
Last
Employed Since
MM
/
DD
/
YYYY
2nd Current Employer Name:
First
Last
Employed Since
MM
/
DD
/
YYYY
