FAMILY COMPOSITION AND ADDRESS VERIFICATION

FAMILY COMPOSITION AND ADDRESS VERIFICATION
Name of family member
(Start with yourself)
Age
Your age
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Name of family member
Other person living in the home
Relationship to applicant
Age
Age of family member
Social Security Number
Last four digits only
Physical address
Street, City, State, ZIP
Signature of Applicant *

Clear
Date *

Month Day Year
Date
Signature of Parent/Guardian (if under the age of 18)

Clear
Date

Month Day Year
Date
You will need to print this form and have a person who does not live in your household complete the ENTIRE GRAY section. The person completing this section is attenting that the individuals listed above reside in the applicant's household. After completion, the form should be emailed to tmorgan@nwgrc.org or faxed to 706.802.5567.
NOTE: Falsification of data on this form is a crime against federal and state laws. Falsification of or concealment of information is punishable by a fine or imprisonment or both and will require repayment of any monies paid to or on behalf of the applicant while in a Georgia job training program.
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