• REEXAMINATION FORM

    REEXAMINATION FORM

  • Date
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  •  -

  • For Statistical Purposes Only

  • Race of Head:
  • Ethnicity of Head:

  • Family Information

  • Head of Household Date of Birth
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  • Family Member #2 Date of Birth
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  • Family Member #3 Date of Birth
     / /
  • Family Member #4 Date of Birth
     / /
  • Family Member #5 Date of Birth
     / /
  • Family Member #6 Date of Birth
     / /
  • Family Member #7 Date of Birth
     / /

  • 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.

  • Rows
  • Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds, etc?*
  • Do you own any real estate?*
  • Have you sold any real estate in the past two years?

  • Deductions in Calculating Rent

  • Is the head of household or spouse age 62 or older OR a person with a disability?
  • Does your household have any medical expenses (include insurance, Medicare deduction, doctor visits, hospital, clinic costs, medicine, therapy, supplies, medical transportation, etc?
  • Do you have any expenses on behalf of a household member with disabilities so an adult in the family can work?
  • Do you have childcare expenses for children under age 13 so an adult in the family can work, go to school or attend job training?
  • Other than the head of household / spouse: is any member of the family 18 or older a full time student or a person with a disability
  • Has anyone in the household been arrested or convicted of a crime within the last 12 months?

  • For any vehicle that you own

  • Date
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  • Date
     / /

  • Click the Submit button below to submit this form.  You will then have additional forms that will automatically open after you click Submit each time.  All of these forms are needed to complete your annual recertification.  After you have completed the last form you will be able to attach any supportive documentation.

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