Please include the following information for each other member of your household, not including yourself:
Name, Date of Birth, Relationship, M/F, Disabled (Y/N), Ethnicity, Education Level, SNAP, Health Insurance, Vet (Y/N), Monthly Income including sources
By submitting this form, I do solemnly swear that the above information is true, correct and complete to the best of my knowledge. I understand that any false statements or misrepresentation may result in my being found ineligible for program participation, up to an including termination from a program. I consent to any inquiries to verify or confirm the information provided on this application.
