Morning
Star of Highlands Co. Inc.
930 West Main
St.
Avon Park, Florida 33825
Last Name_______________ First Name _____________Initial
________ SSN ______
Street _________________________ City ________________
Date _______
Zip
Code ___________ DOB _______________ # Of Years ______ Household Siz___
Previous Addresses _______________________________________________________
Number of Years at Previous
Addresses ________ Male _______ Female ___________
Applicant Marital State Married
Single Divorced Widowed Separated
Present Employer ____________________________________
# of Years ________
Previous Employer ___________________________________ # of Years ________
Name of Spouse ________________ DOB ____________
SS# ____________________
Household Members __________________________ # In Household _______________
Name __________________________SS# _____________ DOB
________ Gender ___
1 ___________________________ ___________________
_____________ _______
2 ___________________________
___________________ _____________ _______
3 ___________________________
___________________ _____________ _______
4 ___________________________
___________________ _____________ _______
5 ___________________________
___________________ _____________ _______
6 ___________________________
___________________ _____________ _______
Household
Own Yes No
Rent $ _______
Electric $ _______
Cable $ _________________
Buying $ _____
Phone $ ________ Car Payment $ ___________
Water $ ______
Car Insurance $ ______________
Income Verification
Employment $ ______________ SS# ________________ SSD # ___________________
ADC $ ___________ Unemployment $ ____________ Food Stamps $_______________
Child Support $ ____________ Food Stamps $ ____________ SS# _________________
Referring Agency ___________________
Applicant's Signature ___________________
Person Taking Application ___________________________
