Georgia Department of Human Resources s7

GEORGIA DEPARTMENT OF HUMAN RESOURCES BASIC INFORMATION WORKSHEET

Date referred: Case No. Date completed: County:

PART A. CASE INFORMATION

Case name: (Surname) (Man’s first name, M.I.): (Woman’s first name, M.I.):

DATE: ADDRESS AND DIRECTIONS FOR REACHING HOME TELEPHONE NUMBER (S)

PART B. CLIENT INFORMATION Adult (s) First: Middle:

Surname-male: Ethn: DOB: Social Security No: Medicaid No: Educ.: Date Out:

Surname-female: First: Middle/maiden: Ethn: DOB: Social Security No: Medicaid Educ: Date Out: No:

Child (ren) Surname, first name, Sex Ethn. Date Of Birth Social Security No. Medicaid No. Education Date out middle initial

CPS_450 Basic Information (Revised 09/06) Page 1 of 2 M F

M F PART C. OTHER HOUSEHOLD MEMBER(S)

Surname, first name, Sex Ethn. Date Of Birth Social Security No. Medicaid No. Education Date out middle initial

F (*) PART D. MARRIAGES

Surname, first name, Name of spouse Date of Date Date Date Deceased Social Security middle initial Marriage Separated Divorced No. of spouse (If out of home)

CPS_450 Basic Information (Revised 09/06) Page 2 of 2

(*) PART E. ABSENT PARENT (S)

Related to: Last Known Address & Surname, first name, Sex Ethn. Date of Social (Give Name Remarks middle initial Birth Security No. and No.

PART F. SIGNIFICANT OTHERS NOT IN HOUSEHOLD

Surname, first name, Address, City, State, Zip Relationship Remarks (include phone middle initial no.)

(*) PART G. EMPLOYMENT RECORD OF CLIENT (S)

CPS_450 Basic Information (Revised 09/06) Page 3 of 2 Surname, first name, Employer’s Name and Address Gross Monthly Date of Employment middle initial Wages From (Mo-Yr) to (Mo.-Yr) Fr: To: Fr: To: Fr: To: Fr: To: Fr: To: Fr: To: Fr: To: Fr: To: PART H. OTHER CLIENT INFORMATION (*) Read instructions carefully before completing.

CPS_450 Basic Information (Revised 09/06) Page 4 of 2