Review

Pre-Qualification
Select the county in which you live


Do your total family assets exceed $1,000,000?


Select your parental household status


Based on the household member definition above, how many people are in your household including yourself?
0

Is your gross family income (before taxes) less than per month?



Personal Information
First Name


Middle Initial


Last Name


Date of birth (person completing application)
1/1/0001 12:00:00 AM

SSN (last 4 digits) For ID Purposes Voluntary


Primary Phone Number


Alternate phone number


Email Address


Physical Address


Apt#


City


State


Zip Code


Mailing Address


Apt#


City


State


Zip Code


Gender


Race/Ethnicity


What is the primary language spoken in your home?


Marital Status


Are you currently 19 years old or younger and attending high school or equivalent?


What is the name of the school you currently attend?


Are you or your spouse a federally qualified Veteran?


Are you or your spouse deployed military?


Are you currently a Foster Youth?


Are you a former Foster Youth and currently younger than 23 years of age?


Does the child(ren) needing care currently receive services through Child Protective Services (CPS)?


Have you received Temporary Assistance for Needy Families (TANF) in the past 30 days?


Are you homeless or without a consistent residence?


Is your name currently on a lease?


Do you currently own a home?


Which of the following situations describes your family’s current night-time residence? (you can choose more than one)


If your family is living in shared housing, please check all of the following reasons that apply


Have you received an eviction notice?


Does the child(ren) needing care have a disability?


Are you the parent with primary custody of the child(ren) needing care?


Does each parent and step-parent living in your household work/attend school at least an average of 25 hours each week or are they actively looking for employment?


Reason


Other Reason



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