Household
Home state:
Select State
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*
Home county:
Select County
Living status:
Select Status
Own Home
Rent Home
Live With Family
Other
*
Date of birth:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
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18
19
20
21
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24
25
26
27
28
29
30
31
Year
2012
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2005
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2003
2002
2001
2000
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1913
1912
1911
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1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
*
Are you married?
Yes
No
*
Is there anyone under age 18 living in your home?
Yes
No
*
*
Indicates required field
Personal
Are you enrolled in Medicare?
Yes
No
Not Sure
*
Is your spouse enrolled in Medicare?
Yes
No
Not Sure
*
Are you enrolled in Medicaid?
Yes
No
Not Sure
*
Do you receive SSI or SSDI?
Yes
No
Not Sure
*
Are you a veteran of the U.S. armed forces?
Yes
No
Not Sure
*
Do you have a medical condition that prevents you from working?
Yes
No
Not Sure
*
Financial
Are you employed?
Yes
No
*
Is your spouse employed?
Yes
No
*
Monthly wages:
*
Spouse monthly wages:
*
Monthly unearned income:
*
Spouse monthly unearned income:
*
Total assets:
*
*
Indicates required field
Lifestyle
Electric energy provider:
Select Provider
Gas energy provider:
Select Provider
Telephone provider:
Select Provider
Cellular telephone provider:
Select Provider
Are you interested in food programs?
Yes
No
*
*
Indicates required field
Medical
Check here if you need help with prescription medication(s)
I have cardiovascular disease
I have diabetes
I have a mental health condition
I have cancer
I take prescription medication(s) for pain
I have a respiratory disease
I have multiple sclerosis (MS)
I have an immune disease
I have an eye condition
I take/need antibiotics
I have a genetic disorder
My condition is not listed
*
Please check one or more medical conditions.
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