Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non Conformingg   
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino       
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non-Conforming
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:    Type a label             
Social Security Number:   Social   
US Military Veteran:   Ty Yes    Ty No    
Date of Birth:   Date   
Gender:   Ty Female    Ty Male    Ty Trans Gender    Ty Gender Non Conformingg   
Race:   Ty American Indian or Alaskan Native    Ty Asian    Ty African American    
Ty Native Hawiian or Pacific Islander    Ty White    
Ethnicity:   Ty Hispanic/Latino    Ty Non Hispanic/Non Latino    
Are you disabled?   Ty Yes    Ty No    
Do you have a disability determination from government?   Ty Yes    Ty No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?   Ty Yes    Ty No    
Are you able to live independently?   Ty Yes    Ty No             

Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non-Conforming   
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes    TNo    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non-Conforming    
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:                         
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non-Conformingg   
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non Conformingg   
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:    Hispanic/Latino     Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Name:   First   Middle   Last   
Relationship to head of household:    Head of HH child     HOH spouse or partner     HOH other relation     Non relation to HOH        
Social Security Number:   Social   
US Military Veteran:    Yes     No    
Date of Birth:   Date   
Gender:    Female     Male     Trans Gender     Gender Non-Conforming    
Race:    American Indian or Alaskan Native     Asian     African American    
Native Hawiian or Pacific Islander     White    
Ethnicity:   Ty Hispanic/Latino    Ty Non Hispanic/Non Latino    
Are you disabled?    Yes     No    
Do you have a disability determination from government?    Yes     No    
Disability Type (select all that apply):     Alcohol Use Disorder     Drug Use Disorder     Chronic Health Condition     Developmental Disorder     HIV/AIDS     Mental Health Disorder     Physical Condition         
Is disability long term?    Yes     No    
Are you able to live independently?    Yes     No             

Who is receiving the income?   First Name      
What is the source of the income?      
How much is the income?   Number   
How often is the income received?    Weekly     Bi-weekly     Monthly    

Who is receiving the income?   First Name      
What is the source of the income?      
How much is the income?   Number   
How often is the income received?    Weekly     Bi-weekly     Monthly    

Who is receiving the income?   First Name      
What is the source of the income?      
How much is the income?   Number   
How often is the income received?    Weekly     Bi-weekly     Monthly