Please Fill out additional members of household - providing this information for each:
Name - Birthday - Gender - Education - Relationship - Amount of Gross Income if Over 18
ex. John Doe - 12/14/1953 - Male - Highschool - Husband - 25k
Failure to report entire household including non-relatives will result in termination of assistance. Failure to report entire household income from all sources will result in termination of assistance.
I certify that all necessary information on income and household has been provided and that all additional information provided on this application is correct.