REEXAMINATION FORM

REEXAMINATION FORM
Name of Head of Household *

First Name Last Name
Date

Month Day Year
Date
Case Worker *
Name of adult Co-Head of Household

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

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

Caucasian/White African American/Black Asian or Pacific Islander Native American/ Alaska Native PacificIslander/Hawaiian Native
Ethnicity of Head:

Hispanic/Latino NonHispanic/NonLatino
Family Information
Head of Household Name

First Name Last Name
Head of Household Date of Birth

Month Day Year
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 Name Last Name
Family Member #2 Date of Birth

Month Day Year
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 Name Last Name
Family Member #3 Date of Birth

Month Day Year
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 Name Last Name
Family Member #4 Date of Birth

Month Day Year
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 Name Last Name
Family Member #5 Date of Birth

Month Day Year
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 Name Last Name
Family Member #6 Date of Birth

Month Day Year
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 Name Last Name
Family Member #7 Date of Birth

Month Day Year
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? *

Yes No
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? *

Yes No
If yes, what is the address?
Have you sold any real estate in the past two years?

Yes No
If yes, what was the address?