<p> GEORGIA DEPARTMENT OF HUMAN RESOURCES BASIC INFORMATION WORKSHEET</p><p>Date referred: Case No. Date completed: County: </p><p>PART A. CASE INFORMATION</p><p>Case name: (Surname) (Man’s first name, M.I.): (Woman’s first name, M.I.):</p><p>DATE: ADDRESS AND DIRECTIONS FOR REACHING HOME TELEPHONE NUMBER (S)</p><p>PART B. CLIENT INFORMATION Adult (s) First: Middle: </p><p>Surname-male: Ethn: DOB: Social Security No: Medicaid No: Educ.: Date Out:</p><p>Surname-female: First: Middle/maiden: Ethn: DOB: Social Security No: Medicaid Educ: Date Out: No: </p><p>Child (ren) Surname, first name, Sex Ethn. Date Of Birth Social Security No. Medicaid No. Education Date out middle initial</p><p>M F</p><p>M F</p><p>M F</p><p>M F</p><p>CPS_450 Basic Information (Revised 09/06) Page 1 of 2 M F</p><p>M F PART C. OTHER HOUSEHOLD MEMBER(S)</p><p>Surname, first name, Sex Ethn. Date Of Birth Social Security No. Medicaid No. Education Date out middle initial</p><p>M</p><p>F</p><p>M</p><p>F</p><p>M F</p><p>M</p><p>F</p><p>M</p><p>F</p><p>M F</p><p>M</p><p>F (*) PART D. MARRIAGES</p><p>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)</p><p>CPS_450 Basic Information (Revised 09/06) Page 2 of 2 </p><p>(*) PART E. ABSENT PARENT (S)</p><p>Related to: Last Known Address & Surname, first name, Sex Ethn. Date of Social (Give Name Remarks middle initial Birth Security No. and No.</p><p>M</p><p>F</p><p>M</p><p>F</p><p>M</p><p>F</p><p>M</p><p>F</p><p>PART F. SIGNIFICANT OTHERS NOT IN HOUSEHOLD</p><p>Surname, first name, Address, City, State, Zip Relationship Remarks (include phone middle initial no.)</p><p>(*) PART G. EMPLOYMENT RECORD OF CLIENT (S)</p><p>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.</p><p>CPS_450 Basic Information (Revised 09/06) Page 4 of 2 </p>