SCSEP Pre-Application Survey

Date
MM slash DD slash YYYY
Phone
Age
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email Address
Check All That Apply
- Veteran
- Spouse of Veteran
- Frail
- Low Literacy, 8th grade or below
- Homeless
- At risk of becoming homeless?
- Limited English
Are you disabled?
If yes, explain
Do you have a criminal background?
If yes, please explain.
Last Employer?
Date last worked?
Barriers to finding employment?
Monthly Income (You) - Wages
Monthly Income (You) - Social Security
Monthly Income (You) - Pension or Retirement
Monthly Income (You) - Other Income Sources
Monthly Income (Spouse) - Wages
Monthly Income (Spouse) - Social Security
Monthly Income (Spouse) - Pension or Retirement
Monthly Income (Spouse) - Other Income Sources
If no income, how do you pay your bills?
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