List all money earned or received by everyone living in the household.
This includes, but is not limited to, gross wages, self employment,
child support, Social Security, SSI, Worker's Compensation, Unemployment benefits,
retirement benefits, TANF, Veteran's benefits, alimony, babysitting,
rental property income. Income from banks such as interest on saving bonds,
checking accounts, and CDs. Also, include any regular contributions to the
household from any person outside the household.
Do any household members have or receive income from assets? (Check all that apply)
If the Head of Household or Spouse are age 62 or older OR disabled regardless of age,
list all medical expenses anticipated for the next 12 months that will not be
reimbursed by insurance or other outside source. (This includes but is not limited
to: prescriptions, physicians bills, hospital bills, insurance premiums, and
over-the-counter medications) Back-up info required.
If yes, please list:
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