Household Information
Name (print): ___________________________________________________________________________________________________
Last
First
Middle
Maiden
Address___________________________________________/_____ Phone: (____)____________Cell or land line?_______
Street
Your # or your contact’s #
Apartment
Phone Company Name_____________
__________________________________________________________Sex: _____ Race: _____ Date of Birth: ____________________
City
State
Social Security Number:
Are you a US Citizen?
/
YES
Zip code
/
Place of Birth: ______________________________________________
NO If no, what is your current status? (circle one) REFUGEE /ASYLEE
The highest grade YOU completed in school (circle one) 0 1 2 3 4 5
Elementary

6 7 8
9 GED 10 11 12
Middle School
High School
LPR
UNDOCUMENTED OTHER
13 14 15 16 16+
College
Please complete the following information for EACH PERSON WHO LIVES WITH YOU:
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
Household Member’s Full Name
Social Security #
Date of Birth
Sex
Race
Relationship to You
Place of
Birth
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
US
CITIZEN?
YES
NO
Highest grade this person completed in school (circle one): 0 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 16+
Your signature: _______________________________________________________________________Today’s date: _____________
Contact name:___________________________________ Contact phone number: _______________________
ADM-1 (3/08)