Food Stamp Worksheet
Brought to you by your friends at Crossroads Urban Center and SLCAP
Income
Hourly wage
Average Hours a week
1st earner*
*
2nd earner
Total Other income (unearned FEP, SSI, GA, Social Security etc.)
Enter Childrens Ages and Child Care costs per month
Child1 Age
Cost
Child2 Age
Cost
Child3 Age
Cost
Child4 Age
Cost
Child5 Age
Cost
Child6 Age
Cost
Child7 Age
Cost
Child8 Age
Cost
Child9 Age
Cost
Child10 Age
Cost
Out of Pocket Medical Costs ($35 will be taken)
Rent/Mortgage costs
Fire Insurance (if any)
Property Tax (if any)
Utility Costs Use $229 unless there are no out of pocket costs
Total # people in household*
Child Support Costs
Elderly or Disabled Person in household
* Required field