Asian Black or African American Native Hawaiian or Pacific Islander White
Permanent Resident Asylee Alien Granted Conditional Entry Parolee (1 yr. or more) Alien Whose Deportation is Withheld
Refugee Battered Alien Spouse, Child, or Parent of Child Undocumented
Child of Lawfully Admitted Alien
1. Is this child receiving Supplemental Security Income (SSI)?
2. What is the child's relationship to you? 1 3. Does this child have a disability?
4. Does this child receive benefits from Social Security?
5. Have you applied for child support for this child? 6. Do you receive child support for this child?
NoIf no, please see instructions on page 6.
7. What is the name of this child's absent parent(s)?
8. Is this child in Head Start?
NoIf yes, what is the start date?
9. If using Informal Relative Care, what is the relationship of the provider to the child?