INFANT AND CHILD INCOME ELIGIBILITY APPLICATION

Foster Infant/Child? Yes No

Homeless Infant/Child? Yes No

Infant/Child from a migrant family? Yes No

Names of All Other Household Members	Monthly Wages/ Salaries	Monthly Social Security	Monthly Public Assistance /Child Support	Monthly Retirement Pensions	Other Monthly Income

ETHNIC IDENTITY: Hispanic or Latino Not Hispanic or Latino

White Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander

I do not have a Social Security Number