APPLICATION FORM

NAME: PHONE: (H) : (W) :

ADDRESS: CITY: STATE: ZIP:

FAMILY SIZE INFORMATION: List all family members living with you (please include your name), their relation to you and any additional income they may receive, including social security, disability, retirement, child support, income from investments, etc.

NAME (S) of all family members (including yourself)	BIRTH DATE	SOCIAL SECURITY NUMBER	RELATION TO YOU	AGE/SEX	GROSS MONTHLY INCOME	SOURCE(S) OF INCOME
1.
2.
3.
4.
5.
6.
7.

The following information is being requested to comply with equal opportunity requirements and to assure that no discrimination occurs. This information will not affect your eligibility for assistance. Please check the appropriate description for the head of household.

___ White ___ Black/African American

___ Indian American/Alaskan Native ___ Asian

___ Native Hawaiian/Other Pacific Islander ___ Asian & White

___ Black/African American & White ___ Am Indian/Alaskan Nat & Black/African Am

___ Balance/Other ___ Hispanic (you may choose this ethnic category, if applicable, in addition to

only one of the above race categories

Are you disabled? Yes_______ No________

I certify that I have reviewed the information given on this form and that all information regarding family composition, income and assets is accurate and complete to the best of my knowledge. I understand that providing false statements and/or information is grounds for termination of this application.

__________________________ ______________

Applicant Signature Date

If you have questions, please contact:

Tresina Lister at 322.9557

or write

TMM Family Services, Inc.

3127 E. Adams St., Tucson, AZ 85716

Equal Housing Opportunity