Center For Common Ground
Form
Name
Email
Phone Number
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Where do you live? (Zip Code)
How old are you?
How many other people besides yourself live in your household?
What is your monthly household income?
What is your household unearned income? (retirement, unemployment, disability, etc)
What is your housing cost per month? (include utilities)
Are heating or cooling bills in your name?
Yes
No
What are your total monthly food costs?
Do you have any children? (anyone in the persons array is < 18)
Yes
No
What are your total monthly childcare costs?
Are you married?
Yes
No
Are you filing taxes separately from your spouse?
Yes
No
Have you lived apart from your spouse for more than six months?
Yes
No
If you have children, was your home the main home of your child?
Yes
No
Cash Assistance
Food Stamps (Current SNAP income (monthly))
Do you have anyone in your household receive Supplemental Security Income (SSI)?
Yes
No
Supplemental Security Income (you): $ (Your SSI Income (monthly))
Supplemental Security Income (spouse): $ (Spouse' SSI income (monthly))
Supplemental Security Income (from all children): $ (Kids' total SSI income (monthly) )
Number of children Supplemental Security Income: (Number of kids receiving SSI)
Security Disability Insurance (total for household): $
Are you unemployed? (Monthly Unemployment income)
Yes
No
Unemployment
Pension
How many hours per week do you pay for child care?
Do you have health insurance?
Yes
No
Health Insurance Cost for Adults
Is your health care subsidized by your employer?
Yes
No
Do your children have health insurance?
Yes
No
Health Insurance Cost for Children
Are you pregnant?
Yes
No
Do you have breast or cervical cancer?
Yes
No
Are you homeless?
Yes
No
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