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Owner or on deed
If the household owns the home, is this person the owner or on the deed?
Yes
Renting and on the rental lease
If the household is renting, is this person on the lease?
Yes
Do any of these apply to the person?
Select all of the following that apply.
Student
Full-time student
Pregnant
Blind
Disabled
Veteran
Unemployed
Unemployed and worked
in the last 18 months
Does this person recieve either of the following benefits?
Select all of the following that apply.
Medicaid
Disability-related Medicaid
Does this person have any income?
This includes money from jobs, alimony, investments, or gifts. You will need to include itemized income. The more income included, the more accurate the screening results will be.
Type *
Please select income type
–––
Wages, salaries, tips
Self-employment Income
Unemployment benefits
Cash Assistance grant
Child Support
Disability-related Medicaid
Supplemental Security Income (SSI)
Social Security Dependent Benefits
Social Security Disability Benefits
Social Security Survivor\'s Benefits
Social Security Retirement Benefits
New York State Disability Benefits
Veteran's Pension or Benefits
Government or Private Pension
Withdrawals from Deferred Compensation (IRA, Keogh, etc.)
Worker's Compensation
Alimony (received)
Boarder or lodger
Gifts/contributions (received)
Rental income
Investment income (interest, dividends, and profit from selling stocks)
Frequency *
Please select income frequency
–––
Every week
Every 2 weeks
Monthly
Twice a month
Every year
Remove this income
Add an Income
Does this person have any expenses?
This includes costs like rent, mortgage, medical bills, child care, child support, and heating bills. You will need to include itemized expenses. The more expenses included, the more accurate the screening results will be.
Type *
Please select expense type
–––
Child Care
Child Support
Dependent Care
Rent
Medical expense
Heating
Cooling
Mortgage
Utilities
Telephone
Third Party Insurance Premiums
Frequency *
Please select expense frenquency
–––
Every week
Every 2 weeks
Monthly
Twice a month
Every year
Remove this expense
Add an Expense
Remove this person
Add Another Person
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