Community Health Center

Household

Clear

Where do you live?

How many people in your household? (include yourself)

Does your household include:

Any children under 19 years old?

Yes No

Any women aged 19 or older?

Yes No

Anyone who is pregnant?

Yes No

How many babies are expected?

Health Insurance

Clear

Does anyone have health insurance now?

Yes No

Did anyone lose their health insurance in the last 6 months?

Yes No

Income

Clear

How many adults in your household have a job right now, (include anyone who earns money through self-employment)?

Are any of them the step-parent of a child in the household?

Yes No

Enter the amount each person earns, before taxes and deductions. If the income is from self-employment, enter the amount earned after business expenses.

Does anyone receive child support payments?

Yes No

How much?

Does anyone receive any other income?

Yes No

How much?

Expenses

Clear

In order to go to work, does anyone in your household pay for child care or for the care of an elderly or disabled family member?

Yes No

How many children under the age of 13 or elderly/disabled persons are receiving care?

Enter the amount paid per month for each person. Check if care is for a child under the age of 2.