Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 3
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295. Is there anyone living with you who is not applying for benefits? ....................
Yes
No
If yes, list below:
Do you purchase and prepare
Name
Relationship to You
food with this person?
Yes
No
Yes
No
Yes
No
D34314000240329
6. Has anyone moved into your home in the past three months? .......................
Yes
No
Name: ___________________________
Date entered the home: _____________
Name: ___________________________
Date entered the home: _____________
7. Answering this question is only required for medical assistance:
Do you plan to file a federal income tax return next year or will you be claimed as a dependent on
someone’s tax return next year? ……......................................................................................................
Yes
No
If yes, complete all columns below (if you are claiming more than 6 dependents, please make a copy of this page
and attach it to your application). In addition to the questions below, please complete Attachment B of this
application for all dependents that are NOT living with you but are claimed on your tax return.
Filing Jointly with Spouse
Dependents listed on your Tax Return
st
1
Tax Filer -or-
Tax Dependent
(applicable to Tax Filers only)
(applicable to Tax Filers only)
Name: ___________________________
First & Last Name: ____________________
Are you filing jointly with
Living with tax filer:
Yes
No
your spouse?
Will you be claimed as a dependent on
Name: ___________________________
someone’s tax return? …
Yes
No
Yes
No
Living with tax filer:
Yes
No
If yes, list name of tax filer and your
If yes, name of spouse:
Name: ___________________________
relationship to the tax filer:
Living with tax filer:
Yes
No
Name:______________________________
_______________________
Name: ___________________________
Living with tax filer:
Yes
No
Name: ___________________________
Relationship:_________________________
Living with tax filer:
Yes
No
Name: ___________________________
Living with tax filer:
Yes
No
Filing Jointly with Spouse
Dependents listed on your Tax Return
nd
2
Tax Filer -or-
Tax Dependent
(applicable to Tax Filers only)
(applicable to Tax Filers only)
Name: ___________________________
First & Last Name: ____________________
Are you filing jointly with
Living with tax filer:
Yes
No
your spouse?
Will you be claimed as a dependent on
Name: ___________________________
someone’s tax return? …
Yes
No
Yes
No
Living with tax filer:
Yes
No
If yes, list name of tax filer and your
If yes, name of spouse:
Name: ___________________________
relationship to the tax filer:
Living with tax filer:
Yes
No
Name:______________________________
_______________________
Name: ___________________________
Living with tax filer:
Yes
No
Relationship:_________________________
Name: ___________________________
Living with tax filer:
Yes
No
Name: ___________________________
Living with tax filer:
Yes
No
Page 3
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