Person One in Household-Primary Contact

Please use full legal name.
First Name	Last Name
Email	Phone Number
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
Marital Status Please select... Married Partnered Single Divorced Widowed Separted	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Mailing Address
Mailing City	Mailing Zip Code
Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student	Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Two in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Three in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Four in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Five in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Six in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Seven in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Eight in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Nine in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Ten in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Eleven in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Twelve in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Thirteen in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Fourteen in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity

Person Fifteen in Household

Please use full legal name.
First Name	Last Name
DOB(MM/DD/YYYY)	Gender Please select... Male Female Non-Binary Prefer Not To Answer
This Person is a  Please select... Infant Child Adult	Ethnicity Please select... Alaska Native/Aleut/Eskimo American Indian/Native American Asian Black/African American Hispanic/Latino Middle-Eastern/North-African Pacific Islander White/Anglo Other Prefer not to Answer
Languages Please select... Amharic Arabic English English/Russian English/Span Spanish Russian Chinese Other	Marital Status Please select... Married Partnered Single Divorced Widowed Separted
Highest Level Of Education Please select... None Pre-School Elementary School Middle School/Junior High School Some High School GED High School Diploma Trade or Vocational Training Some College 2 Years of College Completed(Associates)	Employment Status Please select... Disabled Full-time Homemaker Job-searching Part-time Retired Self-employed Student
Are you Veteran? YesNo	Other Languages
Other Ethnicity