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Check here if any of the following statements apply to you.
• l am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
• I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months;
or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
• During the past year, I was convicted of a felony or released from prison for a felony.
• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year
Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged released from active duty in the U.S. Armed Forces during the past year.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
• Received TANF payments for at least the past 18 months; or • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are a member of a family that:
• Received TANF payments for at least the past 18 months;
or
• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years;
or
• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
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