Agenda - Council - 04/26/2016 - Laserfiche WebLink

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Income Information — Spouse 31. If married, is your spouse employed: Yes No, N/A 32. If yes, spouse's average weekly amount: $ . Employer: (If spouse is working please provide copies of their 2 most recent pay stubs, self-employment records or copies of your most recent tax returns or a statement of employment & income signed by spouse's employer) 33. If your spouse is not currently employed, what was their last date of employment (If spouse's job ended less than 3 months ago, please provide a statement from the former employer showing spouse's last date of work or COBRA statement or termination notice). Financial Information - Other 34. Do you have any unearned income? _Yes _ No (i.e., interest, dividends, insurance payments, Ssr, pensions, VA benefits, alimony, worker's comp, unemployment, social security, Veteran's pensions, etc) 35. if yes, what are the total income amounts & sources: $ Source/s: (Please provide written verification of income, for example, monthly statements, pay stubs, award letters, bank deposits etc.) 36. Do you receive child support: _Yes — No 37. If yes, how much: $ /month (Please provide a copy of your last month's payment received) 38. Do you pay court ordered child support? Yes No 39, If yes, how much do you pay each month: $ (Please provide a copy of your last month's payment or current paystub showing payment.) Referral, Legal and Social Service Information 40. How were you referred to Rule 25? 41. Have you had a chemical use assessment in the past 6 months? Yes No 42. If yes — where? 43. Is this a court ordered assessment? Yes No 44, If yes — which court ordered it? 45. Are you currently in Chemical Dependency Treatment? Yes No 46. If so, which type of program? _ Outpatient(where) Inpatient(where) ,Methadone(where) 47. Are you currently on probation or have a parole officer? Yes _ No 48. If yes: Name: Phone: 49. County: 50. Are you currently working with a county social worker? Yes No 51. if yes: Name: Phone: 52. County: