"Head of Household Form"

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HEAD OF HOUSEHOLD FORM
Please have this form signed by the person with whom you live.
NS#
lives with me at
_________________________________________________________________________________
Do they pay rent? Yes No
If so, how much ?
Do they pay any of the following? (please circle)
Electric Yes
No
How much? ______________ Gas Yes No how much? ______________
Water
Yes
No
How much? ______________ Phone Yes No how much? ____________
Do you or other household members provide the client with any help such as cash, food, clothes, and or
personal items? Yes
No (please circle)
If so, how often do you give client this money?________________________________________________
In past few months, what are the dates and amts of money you have provided the client?
Date _____________________
Amount________________________
Date _____________________
Amount________________________
If you provide non-cash items, what do you provide and how often do you provide it? ________________
Is this a loan? Yes
No (please circle)
If yes, how and when do you expect to be repaid? ______________________________________________
Do you anticipate any changes? Yes
No
If so, What changes do you anticipate? ______________________________________________________
Additional
Comments:____________________________________________________________________________
Your Name:__________________________________________(Please print)
Relationship to member____________________________________________________
Date Sent ____________________
Date Signed _________________________________
Signature: ________________________________________________________________________
Address: ______________________________________________________________________________
CC:
HEAD OF HOUSEHOLD FORM
Please have this form signed by the person with whom you live.
NS#
lives with me at
_________________________________________________________________________________
Do they pay rent? Yes No
If so, how much ?
Do they pay any of the following? (please circle)
Electric Yes
No
How much? ______________ Gas Yes No how much? ______________
Water
Yes
No
How much? ______________ Phone Yes No how much? ____________
Do you or other household members provide the client with any help such as cash, food, clothes, and or
personal items? Yes
No (please circle)
If so, how often do you give client this money?________________________________________________
In past few months, what are the dates and amts of money you have provided the client?
Date _____________________
Amount________________________
Date _____________________
Amount________________________
If you provide non-cash items, what do you provide and how often do you provide it? ________________
Is this a loan? Yes
No (please circle)
If yes, how and when do you expect to be repaid? ______________________________________________
Do you anticipate any changes? Yes
No
If so, What changes do you anticipate? ______________________________________________________
Additional
Comments:____________________________________________________________________________
Your Name:__________________________________________(Please print)
Relationship to member____________________________________________________
Date Sent ____________________
Date Signed _________________________________
Signature: ________________________________________________________________________
Address: ______________________________________________________________________________
CC: