Form Name:Source of Income FormInvestigator Name:Ken KauffmanClick here to view a sample form. Your Full Name*Email Address* Phone*Preferred form of contact Email PhoneLast 4 of SSN*HiddenLAST 4 OF SSNPlease enter a number less than or equal to 9999.Household Income SourcesCheck the appropriate Y/N box to indicate household income sources.01. WAGES FROM EMPLOYMENT (COMMISSIONS, TIPS, BONUSES, ETC)* Yes No02. BUSINESS INCOME (SELF EMPLOYED, AVON, MARY KAY, DAYCARE, ETC)* Yes No03. RENTAL INCOME FROM REAL OR PERSONAL PROPERTY* Yes NoHidden04. INTEREST OR DIVIDENDS FROM ASSETS Yes No05. SOCIAL SECURITY PAYMENTS, VA INCOME, ANNUITIES, INSURANCE, RETIREMENT/PENSIONS OR DEATH BENEFITS* Yes No06. UNEMPLOYMENT PAYMENTS OR DISABILITY PAYMENTS FROM JOB AND FAMILY SERVICES* Yes No07. PUBLIC ASSISTANCE (CASH ASSISTANCE FROM JFS) UTILITY REIMBURSEMENT, ETC.* Yes No08. ALIMONY, CHILD SUPPORT* Yes No09. ANY OTHER SOURCE NOT NAMED ABOVE* Yes NoOTHER SOURCE(S) OF INCOME (PLEASE LIST)*Bank AccountsCheck the appropriate Y/N box to indicate household accounts.10. CHECKING ACCOUNTS (NON CREDIT UNION ACCOUNTS)* Yes No11. SAVING ACCOUNTS (NON CREDIT UNION ACCOUNTS)* Yes No12. CREDIT UNION ACCOUNTS (CHECKING AND/OR SAVINGS)* Yes No13. DIRECT EXPRESS CARDS* Yes No14. UNEMPLOYMENT BENEFIT DEBIT CARD* Yes No15. CHILD SUPPORT DEBIT CARD* Yes No16. ANY OTHER FORM OF DIRECT DEPOSIT DEBIT CARD: (PLEASE LIST) EXAMPLE: EPPI CARD, WALMART PAY CARDS, ETC* Yes NoOTHER FORM OF DIRECT DEPOSIT DEBIT CARD: (PLEASE LIST)*17. CRYPTO CURRENCY ACCOUNTS (COINBASE) IE.. BITCOIN, ETHEREUM, XRP, DOGECOIN, ETC* Yes NoTaxesCheck the appropriate Y/N box to indicate whether any household members have filed taxes for the last year.17. Select and explain* Yes NoExplanation:*APPLICANT SIGNATURE*DATE* Month Day Year