DHS-681 MS Word (10-12) 3
13.
Are you receiving Social Security payments?
Yes
No
If yes, please provide a copy of your award letter or other proof to the FOC with this form, and complete the following:
Date you began receiving payments:
Type of payments:
SSI
Disability
Retirement
Are you permanently disabled according to the Social Security Administration (SSA)?
Yes
No
If yes, please provide proof to the FOC with this form.
14.
Do you have a disability or other health issue(s) that may prevent you from working full-time, or from working at all?
Yes
No
If yes, please provide proof to the FOC with this form.
15.
Do you currently receive public assistance (FIP, Medicaid, Food Stamps, etc.)?
Yes
No
If yes, what kind of assistance?
16.
Are you currently under a bankruptcy plan, or are you in the process of filing for bankruptcy?
Yes
No
17.
Do you expect to receive money from a will, estate, or trust?
Yes
No
18.
Are you currently living in a homeless shelter or taking part in a homelessness program?
Yes
No
If yes, length of time:
19.
In the past six months, have you been unable to pay medical bills (for either yourself or a family member) that you
must pay?
Yes
No
20.
In the past six months, have you been unable to pay other bills that you must pay?
Yes
No
If yes, list bills you are unable to pay:
21.
Do you spend time with your child(ren) on a regular basis, attend school activities, and/or consistently exercise your
court-ordered parenting time?
Yes
No
22.
In addition to your regular parenting time schedule, do you care for your children while the other parent is at work,
at school, etc.?
Yes
No
If yes, list how many hours you do this per week:
23.
Do you provide non-money support (examples: transportation, clothing, etc.) to your children?
Yes
No
24.
Would you be willing to take a finance or budget class?
Yes
No
25.
Would you be willing to attend a jobs program?
Yes
No
26.
Would you be willing to do volunteer work?
Yes
No
If yes, how many hours per week are you willing to volunteer?
MONTHLY INCOME INFORMATION (List gross amounts – before taxes)
Income from job(s) Workers’ compensation Social Security (SSI, disability, retirement, etc.) Veterans Administration (VA) benefits
Unemployment Pension Child support received (for all cases) Spousal support
Settlement (legal settlement, insurance settlement, annuity) Other income (describe source and monthly amount)