IncomeOnEntry

Income at Program Entry

Income and Source		Amount
Earned Income
Unemployment Insurance
Supplemental Security Income or SSI
Supplemental Security Disability Income (SSDI)
Veteran's Disability Income
Private Disability Insurance
Worker's Compensation
Temporary Assistance for Needy Families(TANF)(or use local program name)
General Assistance (GA) (or use local program name)
Retirement income from Social Security
Veteran's pension
Pension from a former job
Child support
Alimony or other spousal support
Other(Please specify):
No financial resources
Total(Calculation)

Source of Non-Cash Benefit
	Food stamps or money for food on a benefits card
	MEDICAID health insurance program (or use local name)
	MEICARE health insurance program (or use local name)
	State Children's Health Insurance Program ( or use local name)
	Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
	Veteran's Administration (VA) Medical Services
	TANF Child Care services (or use local name)
	TANF transportation services (or use local name)
	Other TANF-funded services (or use local name)
	Section 8, public housing, or other rental assistance
	Other Source