IDA Eligibility Quiz

IDA Form – United Way of Essex and West Hudson
Do you have a Social Security or tax ID number? *
 Yes 
 No 
Are you 16 years of age or older? *
 Yes 
 No 
Do you have less than $10,000 in assets, excluding one automobile per household? *
 Yes 
 No 
Do you earn wages from full time work, part-time work or self-employment? *
 Yes 
 No 
Number of people in your household: *
Annual Household Income: *

Round to the nearest dollar
Name *
Prefix

First *

Last *

Suffix

Phone where you can be reached during the day *

### 		-
### 		-
####
Email if available