REEXAMINATION FORM

REEXAMINATION FORM
Name of Head of Household*

First NameLast Name
Date

MonthDayYear
Date
Case Worker*
Name of adult Co-Head of Household

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Email Address
example@example.com
For Statistical Purposes Only
Race of Head:

Caucasian/WhiteAfrican American/BlackAsian or Pacific IslanderNative American/ Alaska NativePacificIslander/Hawaiian Native
Ethnicity of Head:

Hispanic/LatinoNonHispanic/NonLatino
Family Information
Head of Household Name

First NameLast Name
Head of Household Date of Birth

MonthDayYear
Date
Head of Household Gender
Head of Household Social Security Number
Is the Head of Household Disabled?
Head of Household Birthplace Country
Head of Household Marital Status
Is the Head of Household a Full Time Student?
Add Another Family Member 1?

Family Member #2 Name

First NameLast Name
Family Member #2 Date of Birth

MonthDayYear
Date
Family Member #2 Gender
Family Member #2 Social Security Number
Relationship to Head of Household
Is Family Member #2 Disabled?
Family Member #2 Birthplace Country
Family Member #2 Marital Status
Is Family Member #2 a Full Time Student?
Add Another Family Member 2?

Family Member #3 Name

First NameLast Name
Family Member #3 Date of Birth

MonthDayYear
Date
Family Member #3 Gender
Family Member #3 Social Security Number
Relationship to Head of Household
Is Family Member #3 Disabled?
Family member #3 Birthplace Country
Family Member #3 Marital Status
Is Family Member #3 a Full Time Student?
Add Another Family Member 3?

Family Member #4 Name

First NameLast Name
Family Member #4 Date of Birth

MonthDayYear
Date
Family Member #4 Gender
Family member #4 Social Security Number
Relationship to Head of Household
Is Family Member #4 Disabled?
Family member #4 Birthplace Country
Family Member #4 Marital Status
Is Family Member #4 a Full Time Student?
Add Another Family Member 4?

Family Member #5 Name

First NameLast Name
Family Member #5 Date of Birth

MonthDayYear
Date
Family Member #5 Gender
Family Member #5 Social Security Number
Relationship to Head of Household
Is Family Member #5 Disabled?
Family Member #5 Birthplace Country
Family Member #5 Marital Status
Is Family Member #5 a Full Time Student?
Add Another Family Member 5?

Family Member #6 Name

First NameLast Name
Family Member #6 Date of Birth

MonthDayYear
Date
Family Member #6 Gender
Family Member #6 Social Security Number
Relationship to Head of Household
Is Family Member #6 Disabled?
Family Member #6 Birthplace Country
Family Member #6 Marital Status
Is Family Member #6 a Full Time Student?
Add Another Family Member 6?

Family Member #7 Name

First NameLast Name
Family Member #7 Date of Birth

MonthDayYear
Date
Family Member #7 Gender
Family Member #7 Social Security Number
Relationship to Head of Household
Is Family member #7 Disabled?
Family Member #7 Birthplace Country
Family Member #7 Marital Status
Is Family Member #7 Full Time Student?
If you have additional family members please contact your case worker.

Family Income Information

Please list the source and amount of all income expected in the next 12 months for all family members. Include earnings and benefits received from TANF, VA, Social Security, SSI, SSID, Unemployment, Workers Compensation, Child Support, etc. If your family has more than four income sources please list them in the section below the table.

Family Income Information:

	Family Member Name	Income Source	Amount	How often do you receive
1
2
3
4

Additional Family Income. Provide the Family member name, source of income, amount, and frequency of payments.

Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds, etc?*

YesNo
If yes, describe the type of asset(s) (checking account, CD, etc):
What is the market value of all assets? (bank balances, stock value, etc)
Do you own any real estate?*

YesNo
If yes, what is the address?
Have you sold any real estate in the past two years?

YesNo
If yes, what was the address?