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Household Member Information <br /> Name DOB Social Security Number Employment <br /> Veteran ❑ Yes or ❑ No <br /> Ethnicity ❑ Latino or ❑ Non-Latino <br /> Primary Race ❑ Asian ❑ Black/AA ❑ Native American ❑ Native Hawaiian <br /> ❑ White <br /> Marital Status: ❑ Single ❑ Married ❑ Separated ❑ Widow ❑ Divorced <br /> Type of Household: ❑ Single ❑ Couple, no children ❑ 2 Parent Family <br /> ❑ Single Parent ❑ Other (specify) <br /> 30 Day Income Annual Income <br /> Within Income Guidelines ❑ Y ❑ N <br /> Signature: Date: <br /> If you have questions, please call 217-619-9108 <br /> or email: dfa@doveinc.org or shartman@doveinc.org <br />