HEOP Pre-Eligibility Form

Are you a permanent resident of the State of New York?
Are you a ward of the court, have a legal guardian or are currently under foster care?

Household Information

Please provide the following information for all members living in your household: Name, Age, Relationship to Applicant, is person employed or attending college?

(if living in household)
(if living in household)
(if employed)

Required Documents

Please note you will need to provide a signed copy of parent and applicant's 2013 Federal tax returns (if filed) and a copy of all W2s, or an IRS tax transcript of your 2013 Federal tax return and a copy of all W2s.

YesNo
Help with rent?
Food Stamps (SNAP)?
Medical?
Other?
Check all that are applicable. If you marked yes to any above, please provide a statement from the Department of Social Services from which benefits were received during 2013.
If yes, please submit the statement (Form 1099) from the Social Security Administration reporting the benefit total for 2013. Please provide a copy of the 2013 benefit verification letter from Social Security. This letter may be accessed at www.socialsecurity.gov/myaccount or by calling 1-800-772-1213.
If yes, please provide a copy of the 2013 benefit verification letter from SSI. This letter may be accessed at www.socialsecurity.gov/myaccount or by calling 1-800-772-1213.
YesNo
Disability
Unemployment
Veterans Non-Edu Benefits
Living Allowances
Workers Compensation
Untaxed Pensions
Any other income received in 2013 not reported on this form
Please select all that are applicable.