02/22, I am a citizen of the United States or a permanent legal resident., I am presently a student., False, False, I was a student sometime during the past twelve-month period or anticipate becoming a student at sometime during the upcoming twelve-month period., I have a job and receive money/wages, tips or bonuses. (List the businesses or companies that pay you.), I am self-employed or operate my own business. (List the types of jobs you do.), I earn income from periodic, temporary, seasonal or contractual employment/work., I receive Social Security or Rail Road Retirement Act income., I receive Supplemental Security Income (SSI)., I receive quarterly payments from DHS for the State-paid portion of a SSI grant., I receive unearned income for a family member(s) age 17 or under (e.g.: Social Security, trust fund disbursements)., I receive periodic payments from retirement funds or pensions. If yes, how many funds or pensions?, I receive disability or death benefits other than Social Security., I receive Veteran's Administration benefits., I receive Public Assistance. (does not include food stamps or Medicaid), I receive cash contributions or gifts including rent or utility payments, on an ongoing basis from persons not living with me., I receive unemployment benefits., I receive periodic payments from Workers' Compensation., I receive periodic payments from trust, annuity or inheritance. If yes, from how many sources?, I receive income from the rental of real estate or personal property., I receive periodic payments from lottery or other types of winnings., I receive adoption assistance payments., I receive alimony, maintenance, or spousal support., I receive GI Bill benefits., I receive military active duty allotments or regular pay as a member of the National Guard or Reservist pay., I am a member of an Indian Tribe receiving gaming payments., I receive periodic payments from insurance policies or any type of settlement, if yes, how many policies or settlements?, I receive long term care insurance payments that exceed $180/day or $67,000 annually., I receive other recurring or periodic income not listed above. Describe, I receive student financial assistance. (does not include student loans), I receive child support. If yes, from how many parents do you receive support? If yes, is child support paid directly to DHS?, False, I have been awarded a judgment for child support but have not been receiving any payments or have not been receiving the full payments on a regular basis., I anticipate filing a claim for child support within the next twelve months., I have a savings account(s) at:, I have a checking account(s) at:, I have certificates of deposit at:, I have a prepaid card, debit card, paycard, Cash App, Paypal, on which funds from Social Security, SSI, Employment, Child Support, DHS, unemployment or other agency are directly deposited. If yes, how many?, I have cash held in my home or in a safety deposit box., I have savings bonds. If yes, how many?, I have Treasury Bills. If yes, how many?, I have stocks., I have bonds., I have mutual funds or securities., I have IRA's or Keogh account(s) at:, I have time certificate(s) at:, I own real estate and/or receive income from the rental of real estate. If yes, how many properties?, I own a mobile home., I have land contracts. If yes, how many?, I hold a mortgage or deed of trust., I have revocable trusts. If yes, how many trusts?, I have whole life or universal life insurance policy(ies). If yes, how many policies?, I have personal property held for investment purposes (gems, jewelry, collections, etc.)., I have lump sum receipts or one-time receipts., I have another name(s) listed on one or more of the above assets for beneficiary or other purposes, such as, power of attorney. These other persons do not own the assets and receive no income from the assets., I have joint ownership on one or more of the above assets., I have income/assets from sources other than those listed above. (Describe), A member of my household is under the age of 18 and has assets. (Describe), I am Elderly (age 62 or older), Handicapped or Disabled and pay Medicare premiums., I am Elderly (age 62 or older), Handicapped or Disabled and pay medical insurance premiums, other than Medicare., I am Elderly (age 62 or older), Handicapped or Disabled and pay medical or prescription or chore provider expenses which are not reimbursed by insurance., I am Elderly (age 62 or older), Handicapped or Disabled and pay long term care insurance premiums., I pay child care expenses for a child age 12 or under in order to be gainfully employed or to further my education., The Department of Human Services (DHS) pays child care expenses for a child(ren) age 12 or under in order for me to be gainfully employed or further my education. If yes, FIA pays, False, False, I pay handicap care expenses for a handicapped/disabled family member in order to be gainfully employed., I pay handicap equipment expenses for a handicapped/disabled family member that are not covered by insurance., I have provided proof of Social Security number (or certification) for all household members. (The certification for individuals under 18 years of age will be executed by a parent or guardian.), I have sold, given away or otherwise transferred ownership of assets within the last two (2) years. Initial the 'Yes' column or the 'No' column at left. If yes, list item(s) and date(s)