FSS

Household Members*

The head of household receives Section 8 rental assistance through HAYC:*

YesNo
Housing resource center programs I would like information about (check all that apply):

VIDA Program (Valley Individual Development Account)Housing Choice Voucher for Homeownership (HCVH)Credit/Budget CounselingHomeownership CounselingABC's of HomebuyingFinancial LiteracyReady to RentOther
Please fill out the following information for your entire household:

Resource Category*

If yes, please fill out the following information:

Rows	Family Member	Employer / Job Title	Full/Part Time	Rate of Pay $(Hr/Wk/Mo)	Date Employment Started (mm/dd/yyyy)
1
2
3

Employment/Volunteer History (head of household):

Employment Benefits:

Rows	Health	Retirement	Other
Benefits

Source of Family Income: For all family members
Unemployment:
Child Support:
SSI:
Financial Aid:
Disability Payments:
SS:
TANF:
Self Employment:
Earned Income Tax Credit:
General Asst:
Food Stamps:
Medicaid / Children's OHP:
Family Help:
Pension:
Other:
What kind of work interests you?*
What are your career goal(s)?*
What do you need to reach your career goal?*
Higher Education (select all that apply):

AttendingPlanning to attendFinancial aid defaultNot interested

If Attending:

Rows	Name of School	Field of Study	Yrs Attended	Yrs Remaining
Attendance Info

Potential Barriers to Self Sufficiency:
Credit:

None/UnknownPoor Credit (300-579)Fair Credit (580-669)Good Credit (670-739)Very Good Credit (740-799)Excellent Credit (800-850)
Other Barriers (select all that apply):

BudgetingBankruptcyCriminal HistoryReferencesDisabilityEviction or ForeclosureTransportationChildcareOther
What are your strengths?*
What are the biggest challenges that you are facing now?*
FSS Participant Signature*
Date

MonthDayYear
Should be Empty:

FAMILY SELF SUFFICIENCY PROGRAM | FSS