Enter in up to 8 family members living in the household

Check only the one(s) that applies (we will verify all selections)

Current resident of Stephenson County within past 90 days
Victim of Violence Against Women's Reauthorization Act of 2002
Currently meet the HUD/Social Security definition of disabled.
Currently working
Veteran or surviving spouse of Veteran
Involuntarily displaced due to Disaster or Governmental Action
Head of household or spouse is 62 years old or older
Nursing home resident who has resided in a state - licensed nursing home for the past ninety calendar days and have been determined by the state - licensed nursing home as eligible for discharge