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. Do you live in a: 🞏 House 🞏 Apartment 🞏 Mobile home
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. 3a. List yourself, then all other household members. If required, attach separate sheet for more names.
1. Self
6. 7.
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. 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. Indicate the current status of all adults and children that will live in the housing unit to be assisted. Add new members in the space provided below, including the full Social Security Number for each. Enter one of the following codes in box 6 to identify the relationship of each new adult and child listed. H = Head of Household S = Spouse (Married) K = Co-Head (Not Married) F = Xxxxxx Child/Adult Y = Youth Under 18 E = Full Time Student Over 18 L = Live-in Aide A = Other Adult
1. Last Name & Sr, Jr, etc. 2. First Name 3. MI 4. Date of Birth 5. Sex M F 6. Relation H 7. Disabled Yes No
8. Ethnicity (Check One Box) Hispanic/ Not Hispanic/ Latino 2Latino 9. Race (Check All That Apply) White American Indian/Alaska Native Native Hawaiian/ Asian Black/African American Other Pacific Islander 10. Social Security Number 11. Living in Household Yes No
1. Last Name & Sr, Jr, etc. 2. First Name 3. MI 4. Date of Birth 5. Sex M F 6. Relation 7. Disabled Yes No
8. Ethnicity (Check One Box) Hispanic/ Not Hispanic/ Latino Latino 9. Race (Check All That Apply) White American Indian/Alaska Native Native Hawaiian/ Asian Black/African American Other Pacific Islander 10. Social Security Number 11. Living in Household Yes No
1. Last Name & Sr, Jr, etc. 2. First Name 3. MI 4. Date of Birth 5. Sex M F 6. Relation 7. Disabled Yes No
8. Ethnicity (Check One Box) Hispanic/ Not Hispanic/ Latino Latino 9. Race (Check All That Apply) White American Indian/Alaska Native Native Hawaiian/ Asian Black/African American Other Pacific Islander 10. Social Security Number 11. Living in Household Yes No
1. Last Name & Sr, Jr, etc. 2. First Name 3. MI 4. Date of Birth 5. Sex M F 6. Relation 7. Disabled 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. 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. Enter legal address (where the applicant currently lives) and contact information below. If a household is experiencing homelessness or is in temporary housing, provide a mailing address (where the applicant currently receives mail). Legal Address Mailing Address (if different from legal) Street, Apt./Unit # State, CITY, Zip Code Phone Number(s) Email(s) Date of Occupancy
