Family Self Sufficiency Application

Name: _______________________________________ Home Phone #:_____________________

Address: _____________________________________ Work Phone #:______________________

Work Hours: _____________________________________________________________________

Social Security Number:____________________________________________________________

Circle Marital Status: Married Single Separated Divorced Widowed

How many adults live in your home? _________ How many children live in your home?_________

How old are your children?__________________________________________________________

What is your source of income?______________________________________________________

How much education and training do you have?_________________________________________

What type of work would you like to be doing in five years? _______________________________

What is the biggest problem you have in reaching that goal? ______________________________

Are you in school or training? Yes No

If not, would you like to be? Yes No If yes, where? _____________________________

Is there more than one adult in your home who would like to participate? Yes No

Please fill out this application to the best of your ability. We will meet with you individually to go over this information in more detail.

Applicant Signature ____________________________________________ Date________________