Questionnaire Text

Questionnaire form view entire document: text image

f) Any public assistance or welfare payments from the state or local welfare office.

[ ] Yes -->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

Questionnaire instructions view entire document: text image

Mark the "Yes" or "No" box for each type of income, and enter the amount received IN THE PAST 12 MONTHS for each "Yes" response.

If income from any source was received jointly by household members, report, if possible, the appropriate share for each person; otherwise, report the whole amount for only one person and mark the "No" box for the other person.

When reporting income received jointly, DO NOT include the amount for a person not listed on pages 2, 3, or 4.

47f. Include any public assistance or welfare payments the person receives from the state or county welfare office. Do not include assistance received from private charities. Do not include assistance to pay heating or cooling costs.