Missouri Department of Social Services, Family Support Division — Application for Supplemental Nutrition Assistance Program (SNAP) (MO 886-0460 / FS-1) Instructions

Enter the applicant’s full legal first name.

Enter the applicant’s middle name.

Enter the applicant’s last name (family name).

Check this box if you are currently homeless and do not have a stable, permanent place to live.

Enter the applicant’s signature to certify the SNAP application.

Enter the date the applicant signed the application.

Enter the applicant's signature to certify that the information provided is true and complete.

Enter the date the applicant signed the application.

Enter the name(s) of anyone who is a boarder living in your household.

Check this box if anyone in your household receives child support income and you will provide the recipient and gross monthly amount. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the child support income. Fill only if 'Child Support' is 'Yes'.

Enter the last name of the person who receives the child support income. Fill only if 'Child Support' is 'Yes'.

Enter the gross amount of child support received per month. Fill only if 'Child Support' is 'Yes'.

Check this box if you do not want to receive automated phone calls regarding your case at the primary phone number provided.

Check this box if you do not want to receive text messages regarding your case at the primary phone number provided.

Check this box if you do not want to receive either automated phone calls or text messages regarding your case at the primary phone number provided.

Enter the eighth household member’s legal first name.

Enter the eighth household member’s legal last name.

Enter the eighth household member’s sex.

Describe how the eighth household member is related to the applicant (for example, spouse, child, parent, or roommate).

Enter the eighth household member’s date of birth.

Enter the eighth household member’s Social Security Number (if provided).

Indicate whether the eighth household member is Hispanic/Latino.

Enter the race(s) of the eighth household member.

Enter whether the eighth household member buys, cooks, and/or eats with the household (for example, Y or N).

Enter your current email address where you can be contacted.

Check this box if your household’s monthly gross income is less than $150 and you have $100 or less available in cash and/or in a bank account.

Check this box if your household’s monthly gross income is not less than $150 and/or you have more than $100 available in cash and/or in a bank account.

Check this box if your household’s combined monthly gross income and cash on hand (including money in checking/savings) is less than the combined cost of rent/mortgage and utilities.

Check this box if your household’s combined monthly gross income and cash on hand (including money in checking/savings) is not less than the combined cost of rent/mortgage and utilities.

Check this box if anyone in your household is a migrant or seasonal farm worker whose income has stopped and your household has less than $100 in cash and bank accounts.

Check this box if no one in your household is a migrant or seasonal farm worker whose income has stopped and your household has less than $100 in cash and bank accounts.

Check this box if anyone in the household pays an electric bill for the home you live in.

Enter the monthly amount you pay for electric service. Fill only if 'Electric' is 'Yes'.

Enter the first name of the person who pays the electric bill. Fill only if 'Electric' is 'Yes'.

Enter the last name of the person who pays the electric bill. Fill only if 'Electric' is 'Yes'.

Check this box if the electric expense is used to heat or cool your home. Fill only if 'Electric' is 'Yes'.

Check this box if the electric expense is not used to heat or cool your home. Fill only if 'Electric' is 'Yes'.

Check this box if anyone in the household pays for gas service (natural gas or propane) for the home you live in.

Enter the monthly amount you pay for gas service (natural gas and/or propane). Fill only if 'Gas (Natural Gas/Propane)' is 'Yes'.

Enter the first name of the person who pays the gas (natural gas/propane) expense. Fill only if 'Gas (Natural Gas/Propane)' is 'Yes'.

Enter the last name of the person who pays the gas (natural gas/propane) expense. Fill only if 'Gas (Natural Gas/Propane)' is 'Yes'.

Check this box if the gas (natural gas/propane) expense is used to heat or cool your home. Fill only if 'Gas (Natural Gas/Propane)' is 'Yes'.

Check this box if the gas (natural gas/propane) expense is not used to heat or cool your home. Fill only if 'Gas (Natural Gas/Propane)' is 'Yes'.

Check this box if anyone pays homeowners insurance for the home you live in (and it is not already included in the house/mortgage payment).

Enter the amount paid per month for homeowners insurance. Fill only if 'Homeowners Insurance' is 'Yes'.

Enter the first name of the person who pays the homeowners insurance expense. Fill only if 'Homeowners Insurance' is 'Yes'.

Enter the last name of the person who pays the homeowners insurance expense. Fill only if 'Homeowners Insurance' is 'Yes'.

Check this box if anyone in the household pays a house payment (mortgage) for the home you live in.

Enter the monthly amount you pay for the house payment (mortgage). Fill only if 'House Payment (Mortgage)' is 'Yes'.

Enter the first name of the person who pays the house payment (mortgage). Fill only if 'House Payment (Mortgage)' is 'Yes'.

Enter the last name of the person who pays the house payment (mortgage). Fill only if 'House Payment (Mortgage)' is 'Yes'.

Check this box if you pay for another type of fuel for your home (other than electric or natural gas/propane) and will list the fuel type.

Enter the type of other fuel expense you pay for (e.g., oil, wood, pellets, etc.). Fill only if 'Other Fuel (list)' is 'Yes'.

Enter the amount you pay per month for the other fuel expense. Fill only if 'Other Fuel (list)' is 'Yes'.

Enter the first name of the person who pays this other fuel expense. Fill only if 'Other Fuel (list)' is 'Yes'.

Enter the last name of the person who pays this other fuel expense. Fill only if 'Other Fuel (list)' is 'Yes'.

Check this box if the other fuel you listed is used to heat or cool your home. Fill only if 'Other Fuel (list)' is 'Yes'.

Check this box if the other fuel you listed is not used to heat or cool your home. Fill only if 'Other Fuel (list)' is 'Yes'.

Check this box if anyone in your household pays a monthly phone expense for the home you live in.

Enter the monthly amount you pay for phone service. Fill only if 'Phone' is 'Yes'.

Enter the first name of the person who pays the phone expense. Fill only if 'Phone' is 'Yes'.

Enter the last name of the person who pays the phone expense. Fill only if 'Phone' is 'Yes'.

Check this box if anyone pays property taxes for the home you live in.

Enter the monthly amount you pay for property taxes for the home you live in. Fill only if 'Property Taxes' is 'Yes'.

Enter the first name of the person who pays the property taxes. Fill only if 'Property Taxes' is 'Yes'.

Enter the last name of the person who pays the property taxes. Fill only if 'Property Taxes' is 'Yes'.

Check this box if anyone in the household pays rent for the home you live in.

Enter the amount of rent you pay per month for the home you live in. Fill only if 'Rent' is 'Yes'.

Enter the first name of the person who pays the rent. Fill only if 'Rent' is 'Yes'.

Enter the last name of the person who pays the rent. Fill only if 'Rent' is 'Yes'.

Check this box if you pay a sewer expense for the home you live in.

Enter the monthly amount you pay for sewer service. Fill only if 'Sewer' is 'Yes'.

Enter the first name of the person who pays the sewer expense. Fill only if 'Sewer' is 'Yes'.

Enter the last name of the person who pays the sewer expense. Fill only if 'Sewer' is 'Yes'.

Check this box if you (or someone in your household) pays for trash/garbage service for the home you live in.

Enter the monthly amount you pay for trash service. Fill only if 'Trash' is 'Yes'.

Enter the first name of the person who pays the trash expense. Fill only if 'Trash' is 'Yes'.

Enter the last name of the person who pays the trash expense. Fill only if 'Trash' is 'Yes'.

Check this box if anyone in the household pays a water bill for the home you live in.

Enter the monthly amount you pay for water service. Fill only if 'Water' is 'Yes'.

Enter the first name of the person who pays the water bill. Fill only if 'Water' is 'Yes'.

Enter the last name of the person who pays the water bill. Fill only if 'Water' is 'Yes'.

Enter the fifth household member's legal first name.

Enter the fifth household member's legal last name.

Enter the fifth household member's sex.

Enter how the fifth household member is related to the applicant (for example, spouse, child, parent, or other).

Enter the fifth household member's date of birth.

Enter the fifth household member's Social Security Number (if provided).

Indicate whether the fifth household member is Hispanic/Latino.

Enter the fifth household member's race.

Enter whether the fifth household member buys, cooks, and/or eats with the household (Y or N).

Enter the first household member’s legal first name.

Enter the first household member’s legal last name.

Enter the first household member’s sex.

Enter the first household member’s date of birth.

Enter the first household member’s Social Security Number (if available).

Indicate whether the first household member is Hispanic/Latino.

Enter the first household member’s race.

Enter the name(s) of anyone in your household who is a foster child or foster adult.

Enter the fourth household member's legal first name.

Enter the fourth household member's legal last name.

Enter the fourth household member's sex.

Enter how the fourth household member is related to the applicant (for example, spouse, child, parent, roommate).

Provide the fourth household member's date of birth.

Enter the fourth household member's Social Security Number, if available.

Indicate whether the fourth household member is Hispanic and/or Latino.

Enter the race of the fourth household member.

Enter whether the fourth household member buys, cooks, and/or eats with the household.

Check this box if anyone in the household receives money or financial support as gifts, donations, or from relatives. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the gifts, donations, or money from relatives. Fill only if 'Gifts, donations, money from relatives' is 'Yes'.

Enter the last name of the person who receives the gifts, donations, or money from relatives. Fill only if 'Gifts, donations, money from relatives' is 'Yes'.

Enter the gross total monthly amount received from gifts, donations, or money from relatives. Fill only if 'Gifts, donations, money from relatives' is 'Yes'.

Check this box if anyone in the household receives income from guardianship payments or adoption assistance payments. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the guardianship or adoption payments. Fill only if 'Guardianship or Adoption payments' is 'Yes'.

Enter the last name of the person who receives the guardianship or adoption payments. Fill only if 'Guardianship or Adoption payments' is 'Yes'.

Enter the gross monthly amount received from guardianship or adoption payments. Fill only if 'Guardianship or Adoption payments' is 'Yes'.

Enter your home physical street address (street number and street name).

Enter your apartment, building, suite, or trailer number for your home physical address, if applicable.

Enter the city for your home physical address.

Enter the state for your home physical address.

Enter the ZIP code for your home physical address.

Enter the county for your home physical address.

Enter the name of the person who can be contacted to help verify your identity.

Enter the phone number for the person listed to help verify your identity.

Check this box if anyone’s income has stopped or been reduced in the last 30 days.

Check this box if no one’s income has stopped or been reduced in the last 30 days.

Enter the first name of the first person whose income stopped or was reduced in the last 30 days. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the last name of the first person whose income stopped or was reduced in the last 30 days. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the name of the employer for the first person whose income stopped or was reduced. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the employer’s phone number for the first person (if known). Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the date the first person received their final paycheck from this employer. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the gross amount of the first person’s final paycheck. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Check this box if the first person’s income stopping or being reduced was voluntary. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Check this box if the first person’s income stopping or being reduced was not voluntary. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the first name of the second person whose income stopped or was reduced. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the last name of the second person whose income stopped or was reduced. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the name of the employer for the second person whose income stopped or was reduced. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the employer’s phone number for the second person, if known. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the date the second person received their final paycheck. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Enter the gross amount of the second person’s final paycheck. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Check this box if the second person’s income stopped or was reduced voluntarily. Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Check this box if the second person’s income stopped or was reduced involuntarily (not by choice). Fill only if 'Q1 Income Stopped/Reduced in Last 30 Days - Yes' is 'Yes'.

Check this box if anyone earns income from working or is working in exchange for goods and services (in-kind work).

Check this box if no one earns income from working and no one is doing in-kind work in exchange for goods and services.

Enter the first name of the first person who is working or earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the last name of the first person who is working or earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the name of the first person’s employer (or write “self” if self-employed). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the employer’s phone number for the first person, if known. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the first person’s gross income amount received per pay period before taxes or deductions. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Describe how often the first person receives this income (for example, weekly, bi-weekly, or monthly). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the first name of the second person who is working or earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the last name of the second person who is working or earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the name of the employer for the second person (or write “self” if self-employed). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the employer’s phone number for the second person, if known. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the second person’s gross income amount received per pay period before taxes or deductions. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter how often the second person receives this income (for example, weekly, bi-weekly, or monthly). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the first name of the third person who is working and earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the last name of the third person who is working and earning income. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the name of the third person’s employer (or write “self” if self-employed). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the employer’s phone number for the third person, if known. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Enter the third person’s gross income amount received per pay period before taxes or deductions. Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Describe how often the third person receives this income (for example, weekly, bi-weekly, or monthly). Fill only if 'Income Q2 Earned Income / In-Kind Work - Yes' is 'Yes'.

Check this box if anyone receives income or money from any of the listed sources.

Check this box if no one receives income or money from any of the listed sources.

Enter your mailing street address or P.O. Box if it is different from your home (physical) address. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Enter your apartment, building, suite, or trailer number for the mailing address, if applicable. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Enter the city for your mailing address. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Enter the state for your mailing address. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Enter the ZIP code for your mailing address. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Enter the county for your mailing address. Fill only if 'Home (Physical) Address - Street', 'Home (Physical) Address - Apt/Building/Suite/Trailer #', 'Home (Physical) Address - City', 'Home (Physical) Address - State', 'Home (Physical) Address - ZIP Code', 'Home (Physical) Address - County' is different than above (any fields selection).

Check this box if you need a new Missouri EBT card.

Check this box if you do not need a new Missouri EBT card.

Enter the ninth household member's legal first name.

Enter the ninth household member's legal last name.

Enter the ninth household member's sex as shown/used on the form.

Describe how the ninth household member is related to the applicant (for example, spouse, child, parent, or other).

Enter the ninth household member's date of birth.

Enter the ninth household member's Social Security Number, if available.

Indicate whether the ninth household member is Hispanic or Latino.

Enter the ninth household member's race(s) as requested on the form.

Enter whether you buy, cook, and/or eat with the ninth household member in the household.

Enter the name(s) of anyone in your household who is not a U.S. citizen.

Check this box if the first listed income source is an "Other" income source not covered by the categories above and you will provide its details in the first Other sources line below. Fill only if 'Yes' is 'Yes'.

Enter the name or description of the other income source for the first entry. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the first name of the person who receives this other income (first entry). Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the last name of the person who receives this other income (first entry). Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the gross monthly amount received from this other income source for the first entry. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the description/name of the second other income source. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the first name of the person who receives this second other income source. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the last name of the person who receives this second other income source. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the gross monthly amount received from this second other income source. Fill only if 'Other sources (First Entry)' is 'Yes'.

Enter the primary phone number where you can be reached.

Check this box if Phone 1 is a cell/mobile number.

Check this box if Phone 1 is a home phone number.

Check this box if Phone 1 is a work phone number.

Check this box if Phone 1 is another type of phone number not listed (not cell, home, or work).

Enter a phone number that should be used for messages only (such as texts or voicemail) for Phone 1.

Enter the second phone number where you can be reached.

Check this box if the Phone 2 number you provided is a cell/mobile phone.

Check this box if the Phone 2 number you provided is a home phone number.

Check this box if the Phone 2 number you provided is a work phone number.

Check this box if the Phone 2 number you provided is another type of phone number not listed (not cell, home, or work).

Check this box if calling you is the best way for the agency to contact you.

Check this box if email is the best way for the agency to contact you.

Check this box if postal mail is the best way for the agency to contact you.

Check this box if text messages are the best way for the agency to contact you (where available).

Check this box if English is your preferred language.

Check this box if English is not your preferred language.

Enter the language that is spoken most often in your home if English is not your preferred language. Fill only if 'Preferred Language (English) - No' is 'Yes'.

Check this box if anyone pays court-ordered child support and/or alimony.

Check this box if no one pays court-ordered child support and/or alimony.

Enter the first name of the person who pays the court-ordered child support and/or alimony. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the last name of the person who pays the court-ordered child support and/or alimony. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the name of the person or organization that receives the child support and/or alimony payment. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the amount paid for the child support and/or alimony payment. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter how often the child support and/or alimony is paid (for example, weekly, monthly, or biweekly). Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the first name of the second person who pays the court-ordered child support and/or alimony. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the last name of the second person who pays the court-ordered child support and/or alimony. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the name of the person or organization that the second payer pays the child support and/or alimony to. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the amount of child support and/or alimony paid by the second payer each time a payment is made. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter how often the second payer makes the child support and/or alimony payment (for example, weekly or monthly). Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the first name of the person who pays the court-ordered child support and/or alimony for this third entry. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the last name of the person who pays the court-ordered child support and/or alimony for this third entry. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the name of the person or agency that receives the child support and/or alimony payment for this third entry. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter the dollar amount paid for child support and/or alimony for this third entry. Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Enter how often the child support and/or alimony is paid for this third entry (for example, weekly or monthly). Fill only if 'Q2 Child Support/Alimony - Yes' is 'Yes'.

Check this box if anyone in the household age 18 or older is enrolled in school.

Check this box if no one in the household age 18 or older is enrolled in school.

Enter the first name of the first person in the household who is age 18 or older and enrolled in school. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the last name of the first person in the household who is age 18 or older and enrolled in school. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the name of the school the first enrolled person attends. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the type of school the first enrolled person attends (for example, high school, college, vocational, or graduate school). Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the number of hours per semester the first enrolled person is attending school. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter whether the first enrolled person participates in a work-study program (Yes or No). Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the first name of the second household member age 18 or older who is enrolled in school. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the last name of the second household member age 18 or older who is enrolled in school. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the name of the school where the second enrolled household member attends. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the type of school the second enrolled household member attends (for example, college, university, vocational, or trade school). Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the number of hours per semester the second enrolled household member is taking. Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter whether the second enrolled household member participates in a work-study program (Yes or No). Fill only if 'Q2 School Enrollment (Age 18+) - Yes' is 'Yes'.

Enter the first name of the person who pays the child/adult care costs for this first entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the last name of the person who pays the child/adult care costs for this first entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the name of the person who receives the child or adult care for this first entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the amount paid for child/adult care costs for this first entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter how often the child/adult care costs are paid for this first entry (for example, weekly or monthly). Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the total miles driven per month to and from the daycare/provider for this first entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the first name of the person who pays the child or adult care costs for this second entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the last name of the person who pays the child or adult care costs for this second entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the name of the person who receives the child or adult care associated with this second entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the amount paid for the child or adult care costs for this second entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Describe how often the child or adult care costs are paid for this second entry (for example, weekly or monthly). Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the total miles driven per month to and from the daycare or care provider for this second entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the first name of the person who pays the child/adult care cost for this third entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the last name of the person who pays the child/adult care cost for this third entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the name of the person who receives the child or adult care for this third entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the amount paid for the child/adult care cost for this third entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter how often the child/adult care cost is paid for this third entry (for example, weekly or monthly). Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Enter the total miles traveled per month to and from the daycare provider for this third entry. Fill only if 'Q3 Child/Adult Care Costs - Yes' is 'Yes'.

Check this box if anyone is responsible to pay for child or adult care costs (including sliding fees, co-pays, and mileage to or from a daycare provider).

Check this box if no one is responsible to pay for any child or adult care costs (including sliding fees, co-pays, and mileage to or from a daycare provider).

Enter the first name of the first person in the household who is disabled. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter the last name of the first person in the household who is disabled. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter the date the first person's disability began. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter whether the first person's disability is permanent (Yes or No). Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter the first name of the second household member who is disabled. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter the last name of the second household member who is disabled. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Enter the date the second household member’s disability began. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Indicate whether the second household member’s disability is permanent by entering Yes or No. Fill only if 'Q3 Disability in Household: Yes' is 'Yes'.

Check this box if anyone in the household is disabled.

Check this box if no one in the household is disabled.

Enter the first name of the person who is billed for this medical expense (fifth entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the last name of the person who is billed for this medical expense (fifth entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Describe the type of unreimbursed medical expense (for example, co-pay, prescription, premium, hospital bill, or transportation) for the fifth entry. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the dollar amount paid for this medical expense for the fifth entry. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter how often this medical expense is billed (for example, weekly, monthly, or one-time) for the fifth entry. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the total miles per month traveled to and from the medical provider for this expense (fifth entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the first name of the person who is billed for the unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the last name of the person who is billed for the unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Describe the type of unreimbursed medical expense (for example, co-pay, prescription, insurance premium, hospital bill, or in-home care). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the amount paid for this unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

State how often this medical expense is billed (for example, weekly, monthly, or one-time). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the total miles traveled per month to and from the medical provider for this expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the first name of the person who is billed for this medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the last name of the person who is billed for this medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Describe the type of unreimbursed medical expense (e.g., co-pay, premium, prescription, hospital bill, in-home care). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the amount paid for this medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter how often this medical expense is billed (for example, monthly, weekly, or one-time). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the total miles traveled per month for medical care related to this expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the first name of the person who is billed for this unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the last name of the person who is billed for this unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Describe the type of unreimbursed medical expense (for example, doctor visit copay, prescription, insurance premium, or hospital bill). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the amount paid for this unreimbursed medical expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter how often this medical expense is billed (for example, weekly, monthly, or one-time). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the number of miles traveled per month for medical care related to this expense. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the first name of the person who is billed for this medical expense (third entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the last name of the person who is billed for this medical expense (third entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Describe the type of unreimbursed medical expense (e.g., copay, premium, prescription) for this third entry. Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the amount paid for this unreimbursed medical expense (third entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter how often this medical expense is billed (third entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Enter the total miles traveled per month for medical care related to this expense (third entry). Fill only if 'Q4 Unreimbursed medical expenses (Disabled or 60+) - Yes' is 'Yes'.

Check this box if anyone who is disabled or age 60 or older has unreimbursed medical expenses (for example co-pays, insurance/Medicare premiums, prescriptions, hospital bills, in-home care, medical transportation, dentures, hearing aids, or eyeglasses).

Check this box if no one who is disabled or age 60 or older has any unreimbursed medical expenses.

Enter the type of resource account (e.g., checking, savings, CD, IRA, trust, stock, bond, or digital cash account) for the first listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the current balance or cash value of the first listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the name of the bank or financial institution where the first listed account is held. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the first name of the person who owns the first listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the last name of the person who owns the first listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the type of the fourth resource account (for example, checking, savings, CD, IRA, trust, stock, bond, or digital cash account). Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the current balance or cash value of the fourth resource account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the name of the bank or financial institution where the fourth resource account is held. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the first name of the person who owns the fourth resource account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the last name of the person who owns the fourth resource account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the type of resource account for the second account (e.g., checking, savings, CD, IRA, trust, stock, bond, digital cash). Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the current balance or cash value of the second account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the name of the bank or financial institution where the second account is held. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the first name of the person who owns the second account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the last name of the person who owns the second account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the type of resource account for the third listed account (e.g., checking, savings, IRA, CD, trust, stock, bond, or digital cash account). Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the current balance or cash value of the third listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the name of the bank or financial institution where the third listed account is held. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the first name of the person who owns the third listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Enter the last name of the person who owns the third listed account. Fill only if 'Resources accounts/assets - Yes' is 'Yes'.

Check this box if anyone has (or is named on) any checking/savings accounts, debit cards, CDs, IRAs/retirement accounts, trusts, stocks, bonds, or digital cash accounts.

Check this box if no one has (and no one is named on) any checking/savings accounts, debit cards, CDs, IRAs/retirement accounts, trusts, stocks, bonds, or digital cash accounts.

Check this box if anyone receives income from a retirement plan or pension. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the retirement or pension income. Fill only if 'Retirement or Pension' is 'Yes'.

Enter the last name of the person who receives the retirement or pension income. Fill only if 'Retirement or Pension' is 'Yes'.

Enter the gross monthly amount received from the retirement or pension. Fill only if 'Retirement or Pension' is 'Yes'.

Enter the second household member’s legal first name.

Enter the second household member’s legal last name.

Enter the second household member’s sex.

Enter how the second household member is related to the applicant (for example, spouse, child, parent, or other).

Enter the second household member’s date of birth.

Enter the second household member’s Social Security number, if they have one.

Enter whether the second household member is Hispanic and/or Latino.

Enter the second household member’s race.

Enter whether you buy, cook, and/or eat with the second household member (for example, Y or N).

Check this box if you or any household member has been convicted of buying or selling SNAP benefits of $500 or more after 9-22-96.

Check this box if neither you nor any household member has been convicted of buying or selling SNAP benefits of $500 or more after 9-22-96.

Enter the first name of the household member who was convicted of buying or selling SNAP benefits of $500 or more (if the answer to Q1 is yes). Fill only if 'Q1 Yes — Convicted of buying/selling $500+ SNAP benefits' is 'Yes'.

Enter the last name of the household member who was convicted of buying or selling SNAP benefits of $500 or more (if the answer to Q1 is yes). Fill only if 'Q1 Yes — Convicted of buying/selling $500+ SNAP benefits' is 'Yes'.

Check this box if you or any household member is hiding or running from the law to avoid felony prosecution, custody, or jail.

Check this box if no one in your household is hiding or running from the law to avoid felony prosecution, custody, or jail.

Enter the first name of the household member who is hiding or running from the law to avoid felony prosecution, custody, or jail. Fill only if 'Section 4 Q2 - Yes' is 'Yes'.

Enter the last name of the household member who is hiding or running from the law to avoid felony prosecution, custody, or jail. Fill only if 'Section 4 Q2 - Yes' is 'Yes'.

Check this box if you or any member of your household is violating a condition of probation or parole.

Check this box if neither you nor any member of your household is violating a condition of probation or parole.

Enter the first name of the household member who is violating a condition of probation or parole, if the answer to Question 3 is yes. Fill only if 'Section 4 Q3 - Probation/parole violation (Yes)' is 'Yes'.

Enter the last name of the household member who is violating a condition of probation or parole, if the answer to Question 3 is yes. Fill only if 'Section 4 Q3 - Probation/parole violation (Yes)' is 'Yes'.

Check this box if you or anyone in your household made false statements about identity or address to receive SNAP benefits in 2 or more households at the same time.

Check this box if no one in your household made false statements about identity or address to receive SNAP benefits in 2 or more households at the same time.

Enter the first name of the household member who made false identity or address statements to receive SNAP benefits in two or more households at the same time. Fill only if 'Section 4 Q4 - Yes' is 'Yes'.

Enter the last name of the household member who made false identity or address statements to receive SNAP benefits in two or more households at the same time. Fill only if 'Section 4 Q4 - Yes' is 'Yes'.

Check this box if you or any household member has been convicted (after 8-22-96) in federal or state court of a felony related to illegal possession, use, or distribution of a controlled substance.

Check this box if no one in your household has been convicted (after 8-22-96) of a felony related to illegal possession, use, or distribution of a controlled substance.

Enter the first name of the household member who has a felony drug-related conviction after 8-22-96, if the answer to Question 5 is yes. Fill only if 'Section 4 Q5 - Yes' is 'Yes'.

Enter the last name of the household member who has a felony drug-related conviction after 8-22-96, if the answer to Question 5 is yes. Fill only if 'Section 4 Q5 - Yes' is 'Yes'.

Check this box if you or any household member has been convicted of fraudulently receiving duplicate SNAP benefits in any state after 9-22-96.

Check this box if neither you nor any household member has been convicted of fraudulently receiving duplicate SNAP benefits in any state after 9-22-96.

Enter the first name of the household member who was convicted of fraudulently receiving duplicate SNAP benefits after 9-22-96. Fill only if 'Section 4 Q6 - Yes (Fraudulently receiving duplicate SNAP benefits after 9-22-96)' is 'Yes'.

Enter the last name of the household member who was convicted of fraudulently receiving duplicate SNAP benefits after 9-22-96. Fill only if 'Section 4 Q6 - Yes (Fraudulently receiving duplicate SNAP benefits after 9-22-96)' is 'Yes'.

Check this box if you or any household member has been convicted of trading SNAP benefits for guns, ammunition, or explosives after 9-01-94.

Check this box if no one in your household has been convicted of trading SNAP benefits for guns, ammunition, or explosives after 9-01-94.

Enter the first name of the household member convicted of trading SNAP benefits for guns, ammunition, or explosives after 9-01-94. Fill only if 'Section 4 Q7 - Yes (Traded SNAP benefits for guns/ammunition/explosives after 9-01-94 conviction)' is 'Yes'.

Enter the last name of the household member convicted of trading SNAP benefits for guns, ammunition, or explosives after 9-01-94. Fill only if 'Section 4 Q7 - Yes (Traded SNAP benefits for guns/ammunition/explosives after 9-01-94 conviction)' is 'Yes'.

Check this box if you or any household member has been convicted of trading SNAP benefits for drugs after 9-01-94.

Check this box if neither you nor any household member has been convicted of trading SNAP benefits for drugs after 9-01-94.

Enter the first name of the household member who was convicted of trading SNAP benefits for drugs after 9-01-94, if the answer to Q8 is yes. Fill only if 'Section 4 Q8 - Yes (Traded SNAP benefits for drugs after 9-01-94 conviction)' is 'Yes'.

Enter the last name of the household member who was convicted of trading SNAP benefits for drugs after 9-01-94, if the answer to Q8 is yes. Fill only if 'Section 4 Q8 - Yes (Traded SNAP benefits for drugs after 9-01-94 conviction)' is 'Yes'.

Check this box if anyone in your household has been convicted since 2-07-14 of one or more of the listed crimes (aggravated sexual abuse, murder, sexual exploitation/abuse of children, or sexual assault).

Check this box if no one in your household has been convicted since 2-07-14 of any of the listed crimes.

Enter the first name of the household member who has been convicted of one or more of the listed crimes since 2-07-14. Fill only if 'Q9 Yes' is 'Yes'.

Enter the last name of the household member who has been convicted of one or more of the listed crimes since 2-07-14. Fill only if 'Q9 Yes' is 'Yes'.

List which of the crimes shown in Question 9 the household member was convicted of since 2-07-14. Fill only if 'Q9 Yes' is 'Yes'.

Enter the first name of the person who received SNAP benefits in another state within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the last name of the person who received SNAP benefits in another state within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the state where this person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the county in the other state where this person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the date this person last received SNAP benefits in the other state. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the first name of the second person who received SNAP benefits in a state other than Missouri within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the last name of the second person who received SNAP benefits in a state other than Missouri within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the state where the second person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the county in the other state where the second person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the date the second person last received SNAP benefits in the other state. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the first name of the third person who received SNAP benefits in another state within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the last name of the third person who received SNAP benefits in another state within the past 30 days. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the state where the third person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the county in the other state where the third person last received SNAP benefits. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Enter the date the third person last received SNAP benefits in the other state. Fill only if 'Section 5 Q1 - Yes' is 'Yes'.

Check this box if anyone in the household received SNAP benefits in a state other than Missouri within the past 30 days.

Check this box if no one in the household received SNAP benefits in a state other than Missouri within the past 30 days.

Enter the seventh household member’s legal first name.

Enter the seventh household member’s legal last name.

Enter the seventh household member’s sex as listed on the form.

Enter how the seventh household member is related to the applicant (e.g., spouse, child, parent).

Enter the seventh household member’s date of birth.

Enter the seventh household member’s Social Security Number (if available).

Indicate whether the seventh household member is Hispanic or Latino.

Enter the seventh household member’s race.

Enter whether the seventh household member buys, cooks, and/or eats with the household.

Enter the sixth household member’s legal first name.

Enter the sixth household member’s legal last name.

Enter the sixth household member’s sex.

Enter how the sixth household member is related to the applicant (for example, spouse, child, parent, or other).

Enter the sixth household member’s date of birth.

Enter the sixth household member’s Social Security Number (if they have one).

Indicate whether the sixth household member is Hispanic and/or Latino.

Enter the sixth household member’s race.

Enter whether the sixth household member buys, cooks, and/or eats with the household.

Check this box if anyone receives Social Security Income from retirement, survivor, or disability benefits. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives Social Security income. Fill only if 'Social Security Income (retirement, survivors, or disability)' is 'Yes'.

Enter the last name of the person who receives Social Security income. Fill only if 'Social Security Income (retirement, survivors, or disability)' is 'Yes'.

Enter the gross monthly amount of Social Security income the person receives. Fill only if 'Social Security Income (retirement, survivors, or disability)' is 'Yes'.

Check this box if anyone receives money or income from student loans, grants, or scholarships. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the student loans, grants, or scholarships income. Fill only if 'Student loans, grants, scholarships' is 'Yes'.

Enter the last name of the person who receives the student loans, grants, or scholarships income. Fill only if 'Student loans, grants, scholarships' is 'Yes'.

Enter the gross monthly amount received from student loans, grants, or scholarships. Fill only if 'Student loans, grants, scholarships' is 'Yes'.

Check this box if anyone in the household receives Supplemental Security Income (SSI). Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives Supplemental Security Income (SSI). Fill only if 'Supplemental Security Income (SSI)' is 'Yes'.

Enter the last name of the person who receives Supplemental Security Income (SSI). Fill only if 'Supplemental Security Income (SSI)' is 'Yes'.

Enter the gross monthly amount of Supplemental Security Income (SSI) received. Fill only if 'Supplemental Security Income (SSI)' is 'Yes'.

Enter the tenth household member's legal first name.

Enter the tenth household member's legal last name.

Enter the tenth household member's sex.

Describe how the tenth household member is related to the applicant (for example, self, spouse, child, or other).

Enter the tenth household member's date of birth.

Enter the tenth household member's Social Security Number (if provided).

Indicate whether the tenth household member is Hispanic and/or Latino.

Enter the race(s) for the tenth household member (list all that apply).

Enter whether you buy, cook, and/or eat with this household member (typically Y or N).

Enter the third household member's legal first name.

Enter the third household member's legal last name.

Enter the third household member's sex.

Enter how the third household member is related to the applicant (for example, spouse, child, parent, roommate).

Enter the third household member's date of birth.

Enter the third household member's Social Security Number.

Indicate whether the third household member is Hispanic or Latino.

Enter the race for the third household member.

Enter whether the third household member buys, cooks, and/or eats with the household (for example, Y or N).

Check this box if anyone in the household receives unemployment benefit payments. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives the unemployment benefits. Fill only if 'Unemployment benefits' is 'Yes'.

Enter the last name of the person who receives the unemployment benefits. Fill only if 'Unemployment benefits' is 'Yes'.

Enter the gross monthly amount of unemployment benefits received. Fill only if 'Unemployment benefits' is 'Yes'.

Check this box if anyone in the household receives income from Veteran’s Administration (VA) benefits. Fill only if 'Yes' is 'Yes'.

Enter the first name of the person who receives Veteran’s Administration (VA) benefits. Fill only if 'Veteran’s Administration Benefits (VA)' is 'Yes'.

Enter the last name of the person who receives Veteran’s Administration (VA) benefits. Fill only if 'Veteran’s Administration Benefits (VA)' is 'Yes'.

Enter the gross monthly amount of Veteran’s Administration (VA) benefits received. Fill only if 'Veteran’s Administration Benefits (VA)' is 'Yes'.

Enter the witness's signature if the applicant cannot sign their own name. Fill only if 'Applicant Signature' is not provided.

Enter the date the witness signed on behalf of the applicant. Fill only if 'Applicant Signature' is not provided.