OTHER HOUSEHOLD MEMBERS. 1. Spouse/Housemate (name/relationship)
2. Children in the home Sex/Age(s)
3. Others in household and relationship
OTHER HOUSEHOLD MEMBERS. Enter Gross Income Under Each Income Type each Household Member Receives and "How Often" the Income is Received by using the Xxxxxxx, Xxxxxx $ 199.98 W $ 141.65 Pension Y $ 99.99 Child Support M $ 550.00 Rental Income M
OTHER HOUSEHOLD MEMBERS. Name all others who will be living in the household.
OTHER HOUSEHOLD MEMBERS describe relationship to applicant, e.g., son, daughter, father, mother, friend, etc. on remaining lines IF NO OTHER HOUSEHOLD MEMBERS, record NONE on line below MAIDEN/ALIAS. *Social Service Law 424a requires the collection of a $25.00 fee for certain categories. A certified check, postal or bank money order, teller's check, cashier's check or agency check made payable to "New York State Office of Children and Family Services" in the amount of twenty-five dollars, is to accompany the form. The check also is to include the applicant's name and the agency code. **Social Service Law 424a, allows local DSS to bill against their reimbursement the charge collected for screening prospective employees. Please access the (OCFS-4627) Request for Forms and Publications, from the Intranet: xxxx://xxxx.xxxxx.xxxxxx/xxxxx/xxxxx/XXX/ Internet: xxxx://xxxx.xx.xxx/main/forms/cps/ and mail the completed OCFS-4627 Request for Forms and Publications, to: Other Household Members are (please print clearly):
OTHER HOUSEHOLD MEMBERS. Enter Gross Income Under Each Income Type each Household Member Receives and "How Often" the Income is Received by using the following Income Codes: W=Weekly, E=Every 2 Weeks, T=Twice a Month, M=Monthly, Y=Yearly. If No Income, You MUST Mark the "No Income box." DO NOT Leave Blank. Adult's Full Name (Do not repeat names from Section A) MARK "X" If No Income Gross Earnings from Work Paid Before Deductions, Include How All jobs Often? Indicate Pay from Pensions, Income Retirement, Social Security, Source? VA benefits Paid How Often? Welfare Benefits, Income Paid Child Support, Source? How Alimony Payments Often? Any Other Income, Including Temporary Income Income Source? Paid HowOften? Enter Benefit Type: CalFresh, CalWORKS, Kin-GAP, FDPIR Enter Benefit Xxxxxxx, Xxxxxx $ 199.98 W $ 141.65 Pension Y $ 99.99 Child Support M $ 550.00 Rental Income M ① $ $ $ $ ② $ $ $ $ ③ $ $ $ $ ④ $ $ $ $ ⑤ $ $ $ $
