Section B: Income Information
Please provide the following information about your household income, which will be used to determine if you are eligible for our services. Please include all income that any member of your household receives. If you do not know exact figures, please provide your best estimate. For example, if your paycheck changes based on the hours you work each week, try to estimate your average weekly or monthly income. If we are not able to help you further based on your household income, the information in this section will not be entered into our system.
Type of Income* Select One Employment Unemployment Worker's Comp Private Disability Social Security SSDI (Social Security Disability) SSI(Supplemental Security Income) IDA (Interim Disability Assistance) Child Support TANF/Welfare Food Stamps General Assistance Pension Trust, Interest, Div. Veteran's Benefits Alimony Other or Unknown My household has zero income
Amount
Frequency Select One Annual Monthly Bi-Weekly Weekly
Type of IncomeSelect One Employment Unemployment Worker's Comp Private Disability Social Security SSDI (Social Security Disability) SSI(Supplemental Security) Income IDA (Interim Disability Assistance) Child Support TANF/Welfare Food Stamps General Assistance Pension Trust, Interest, Div. Veteran's Benefits Alimony Other or Unknown
Amount
Frequency Select One Annual Monthly Bi-Weekly Weekly
Type of IncomeSelect One Employment Unemployment Worker's Comp Private Disability Social Security SSDI (Social Security Disability) SSI(Supplemental Security Income) IDA (Interim Disability Assistance) Child Support TANF/Welfare Food Stamps General Assistance Pension Trust, Interest, Div. Veteran's Benefits Alimony Other or Unknown
Amount
Frequency Select One Annual Monthly Bi-Weekly Weekly
Type of IncomeSelect One Employment Unemployment Worker's Comp Private Disability Social Security SSDI (Social Security Disability) SSI(Supplemental Security Income) IDA (Interim Disability Assistance) Child Support TANF/Welfare Food Stamps General Assistance Pension Trust, Interest, Div. Veteran's Benefits Alimony Other or Unknown
Amount
Frequency Select One Annual Monthly Bi-Weekly Weekly
Type of IncomeSelect One Employment Unemployment Worker's Comp Private Disability Social Security SSDI (Social Security Disability) SSI(Supplemental Security Income IDA (Interim Disability Assistance) Child Support TANF/Welfare Food Stamps General Assistance Pension Trust, Interest, Div. Veteran's Benefits Alimony Other or Unknown
Amount
Frequency Select One Annual Monthly Bi-Weekly Weekly
Tip: If no one in your household receives any form of income, please select the option that says “My household has zero income” in the first drop-down box.
If you are unsure about what kind of income you receive, or you want to give us additional information, please use the box below.
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Section C: Information about your Legal Matter
Please provide the additional information below describing your legal matter. If you have multiple issues, please check all boxes that apply.
If you need to return to an earlier part of the form, please use the “Back” button below instead of your browser’s “Back” button.
Type of Public Benefits issue: Disability/Social Security/SSI TANF (Temporary Aid for Needy Families) Food Stamps Medicaid/Medicare/QMB/Alliance Home Health Aide Unemployment Insurance
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Food Stamps
1. How much in Food Stamps are you currently receiving each month? For how many household members?
2. What problem are you having with Food Stamps?
Food Stamps stopped Food Stamps were reduced Food Stamps application denied Applied for Food Stamps, but haven’t heard anything
a. When did your benefits stop?
b. Did you get any notice about your benefits stopping? If so, what did it say?
c. How much were you getting before your benefits stopped?
a. When were your benefits reduced?
b. Did you get any notice about your benefits being reduced? If so, what did it say?
c. How much were you getting before your benefits were reduced?
a. When did you apply?
b. Did the Department of Human Services (DHS) say why you were denied?
c. Do you disagree with their decision?
a. When did you apply?
3. Did you submit all the paperwork you were supposed to submit? Even if you didn't, please note that we can still consider your case.
Yes No I don't know
4. Did you appeal?
Yes No
We need the following information to figure out how much in Food Stamps you should be getting:
a. How many people in your household buy and/or prepare meals together? Please include adults and children.
b. Please list the income for everyone in your household who buy and/or prepare meals together. This includes earned income (wages) and unearned income (like Social Security, TANF, and child support).
c. How much do you pay in rent or mortgage every month?
d. Do you pay any utility bills? Yes No
e. If applicable, how much do you pay in child support every month?
f. Do you have any medical expenses that are not covered by insurance? If so, how much?
g. If applicable, how much do you pay in childcare expenses every month?
h. Please list the immigration status of you and everyone in your household, including each child. (Note: immigrant parents may apply for food stamps for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible for food stamps.)
Is there anything else we should know about your case?
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