Please check all that apply

• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9months during the past 18 months.• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (foodstamps) for at least a 3-month period during the past 15 months.• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Workprogram, or the Department of Veterans Affairs.• I am at least age 18 but not age 40 or older and I am a member of a family that:a. Received SNAP benefits (food stamps) for the past 6 months; orb. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.• During the past year, I was convicted of a felony or released from prison for a felony.• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during thepast year