Household Information. Household members include: # of Adults # of Children Are there any pets in the household? ◻ Yes ◻ No If yes, what kind and how many? Will Employee be expected to care for the pets? ◻ Yes ◻ No
Household Information. Marital Status (Circle One) Married Single Separated Total in Household: Dependent Name(s) (Attach separate sheet for addtl. dependents) Dependent Date of Birth
III. Employment/Income Patient/Guarantor Employer: Gross Monthly Income Amount: $ Other Income Source and Gross Monthly Amount: $ Total Annual Gross Household Income: $
IV. Insurance Verification Do you have any health insurance? YES NO If yes, please explain: Are you employed? YES NO If Yes, list current employer information: If No, list last employer information (include dates): Community Benefits Report** Direct Community Benefits Community Benefit Reporting Sample
Household Information. Main telephone number of the household: X Main email of the Member: X Names of each additional person living at the above address and approved for occupancy by the Cooperative: Occupant Name: X □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) SAMPLE
Household Information. Today’s Date: / / If you are not the parent of child(ren) for whom you are applying, are you the Primary Adult Caretaker*? Are there other Adult Caretaker(s) in the household*? *Primary Adult Caretaker’s Last Name: *Primary Adult Caretaker’s First Name: Middle Initial: Do any of the following apply to your current living situation? Please complete if applicable. housing such as car, park, etc. Living situation (please explain) Date living situation began: / / Anticipated end date: / / Residence Address*: City*: State*: Zip*: City*: State*: Zip*: County*: Primary language spoken in the home*: Contact Information: *Complete at least one Primary Phone*: ( ) Type: Home Cell Voice Msg. Work Secondary Phone*: ( ) Type: Home Cell Voice Msg. Work Email Address: Colorado Works/TANF cash assistance Head Start/Early Head Start Low-Income Energy Assistance (LEAP) Food Assistance (SNAP) Women, Infants and Children (WIC) Program Child and Adult Care Food Program Medicaid/CHP+ Assistance Housing voucher or cash assistance Refugee Medical Assistance Individuals with Disabilities Education (IDEA) Services Part B (3-5yrs) Individuals with Disabilities Education (IDEA) Services Part C (0-3yrs) Old Age Pension Other (please explain):_ Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1 615-82-14-0028 (rev12/2015) All Items Marked with (*) on this application MUST be completed
Household Information. Please complete this section for the household in which your animal will reside. Living accommodations: Rent Own Other If rent, provide the name and phone no. of your landlord ________________________________________. We must receive written or verbal approval from your landlord before an adoption may be approved. Do you have a fenced- in yard? ______. If no, how will you keep your animal contained? ___________________________ Where will your new pet live? In home In yard Other_________________________ How many adults live in this household? ______ How many children? ______ Ages of children in this household? _________________________ Are all members in your household in agreement about adopting an animal (this includes roommates)? Yes No
Household Information. Marital Status (Circle One) Married Single Separated Total in Household: Dependent Name(s) (Attach separate sheet for addtl. dependents) Dependent Date of Birth
Household Information a. The Nanny may have friends or relatives visit her in the Family home. Yes No
b. We would like the Nanny to answer the telephone in the following manner:
c. We would prefer that the Nanny address us by our: Family name First names
d. The following areas are off limits to the Nanny and child/ren:
e. Our home is child-proofed. Yes No
f. We expect the Nanny to child-proof our home and Family will respect her decisions. Yes No
Household Information. Please list ALL of the people that will occupy the rental unit, including the head of household. Attach an Additional sheet if necessary First & Last Name Birth date Social Security # Relationship Tribe Enroll No. Head of House
12. Are you or your family currently homeless? Yes No
13. Have you or any household member received any type of housing assistance from another federally recognized Native American Tribe? Yes No
14. Have you or any household member received any type of housing assistance from the LTBB Housing Department in the past? Yes No
15. If applicable, provide the name of the person from questions 13 & 14 who received housing assistance Name: Date & Type of Assistance:
Household Information. The nanny may have visitors in the family home. Yes No If yes, 24 hour advance notice must be provided and number of guests should be limited to no more than at a time.
Household Information. 3a. List yourself, then all other household members. If required, attach separate sheet for more names.
1. Self
6. 7.