SCSEP PREAPPLICATION FORM
Case Manger (Office Use Only)
Full Name
Application Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of residence?
Phone Number
-
Area Code
Phone Number
Cell Number
-
Area Code
Phone Number
Email
example@example.com
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex
Male
Female
Other
Ethnicity
Hispanic or Latino
Not Hispanic of Latino
Education
0-8
9-12
High School Grad
GED
Associates Degree
Bachelor Degree
Master Degree
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently employed?
Yes
No
Marital Status
Married
Separated
Single
Widowed
Housing Status
Rent Unsubsidized
Rent Subsidized
Own
Live with Family
Shelter
Homeless
# of people living in your home?
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What is your total income for the past 6 months from today? [Include income of spouse and other relatives (if dependent = they are claimed on taxes) if they live in same house]
Rows
Applicant Income
Spouse Income
Other Income
Social Security Gross
Wages and Salary
Self-Employment Income
Survivors Benefits
Pension/Retirement Income
Interest Income
Dividends
Rents/Royalties/Estates and Trusts
Educational Assistance
Alimony
Financial Assistance from Outside the Household
Other Income
Income Totals
Applicant Total
Spouse Total
Other Total
Disabled:
Work Status
Health Insurance:
Job Experience:
Food Stamps:
Military Status:
If yes, do you have military health care?
Submit
Print Form
Should be Empty: