Household Information. Marital Status (Circle One) Married Single Separated Total in Household: Dependent Name(s) (Attach separate sheet for addtl. dependents) Dependent Date of Birth
Household Information. Please complete this section for the household in which your animal will reside. Living accommodations: Rent Own Other If rent, provide the name and phone no. of your landlord ________________________________________. We must receive written or verbal approval from your landlord before an adoption may be approved. Do you have a fenced- in yard? ______. If no, how will you keep your animal contained? ___________________________ Where will your new pet live? In home In yard Other_________________________ How many adults live in this household? ______ How many children? ______ Ages of children in this household? _________________________ Are all members in your household in agreement about adopting an animal (this includes roommates)? Yes No
Household Information. Household members include: # of Adults # of Children Are there any pets in the household? ◻ Yes ◻ No If yes, what kind and how many? Will Employee be expected to care for the pets? ◻ Yes ◻ No
Household Information. Main telephone number of the household: X Main email of the Member: X Names of each additional person living at the above address and approved for occupancy by the Cooperative: Occupant Name: X □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Additional occupants names: SAMPLE
Household Information. 3a. List yourself, then all other household members. If required, attach separate sheet for more names. Relationship Birth Date Born in Last Name First Name & Initial (to Applicant) (dd/mm/yyyy) Age Sex Canada?
Household Information a. The Nanny may have friends or relatives visit her in the Family home. Yes No
Household Information. Today’s Date: / / If you are not the parent of child(ren) for whom you are applying, are you the Primary Adult Caretaker*? Are there other Adult Caretaker(s) in the household*? *Primary Adult Caretaker’s Last Name: *Primary Adult Caretaker’s First Name: Middle Initial: Do any of the following apply to your current living situation? Please complete if applicable. housing such as car, park, etc. Living situation (please explain) Date living situation began: / / Anticipated end date: / / Residence Address*: City*: State*: Zip*: City*: State*: Zip*: County*: Primary language spoken in the home*: Contact Information: *Complete at least one Primary Phone*: ( ) Type: Home Cell Voice Msg. Work Secondary Phone*: ( ) Type: Home Cell Voice Msg. Work Email Address: Do you or anyone else in your household receive benefits from or participate in any of the following programs? If no, would you like to receive more information? Colorado Works/TANF cash assistance Head Start/Early Head Start Low-Income Energy Assistance (LEAP) Food Assistance (SNAP) Women, Infants and Children (WIC) Program Child and Adult Care Food Program Medicaid/CHP+ Assistance Housing voucher or cash assistance Refugee Medical Assistance Individuals with Disabilities Education (IDEA) Services Part B (3-5yrs) Individuals with Disabilities Education (IDEA) Services Part C (0-3yrs) Old Age Pension Other (please explain):_ Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1 615-82-14-0028 (rev12/2015) All Items Marked with (*) on this application MUST be completed
Household Information. Please list ALL of the people that will occupy the rental unit, including the head of household. Attach an Additional sheet if necessary First & Last Name Birth date Social Security # Relationship Tribe Enroll No. Head of House
Household Information. Indicate the current status of all adults and children that will live in the housing unit to be assisted. Add new members in the space provided below, including the full Social Security Number for each. Enter one of the following codes in box 6 to identify the relationship of each new adult and child listed. H = Head of Household S = Spouse (Married) K = Co-Head (Not Married) F = Xxxxxx Child/Adult Y = Youth Under 18 E = Full Time Student Over 18 L = Live-in Aide A = Other Adult
Household Information a. The nanny may have visitors in the family home. Yes No If yes, 24 hour advance notice must be provided and number of guests should be limited to no more than at a time.
