Household Information Sample Clauses

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 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 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. 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. 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 = ▇▇▇▇▇▇ 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. 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

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. 3a. List yourself, then all other household members. If required, attach separate sheet for more names. 1. Self 6. 7.

Household Information. Do you live in a: 🞏 House 🞏 Apartment 🞏 Mobile home