Offline Easytrak Application (Family Member)
If you have additional family members that you need to send to your Community Resource Specialist, please fill out the form below.
Please choose the Community Resource Specialist you are working with:*
First Name
Middle Initial
Last Name
Date
Month Day Year
Date
Gender
Male Female Unknown
Relation
Head Co-Head Spouse Foster Child Foster Adult Child Live in Aide Parent Stepchild Grandchild Grandparent Related Not Related Girlfriend Boyfriend Other
Race
Unknown Black White Hispanic/Latino Native American/Alaskan Asian Native Hawaiian/Pacific Multi-Racial/Bi-Racial Other
Education
0-8 9-12/Non-grad HS Grad/GED 12+ Some Post 2nd College Grad Graduate School Unknown
Marital
Unknown Married Never Married Divorced Separated Widow Other
Status Demographics
Food Stamps Health Ins. Medicare Ins. Medicaid Ins. Handicap Disabled Disp. Homemaker Head Start Parent Registered Voter Non-US Citizen Drivers License Deceased
Future Education
Enrolled Planning None
Please select if family member DOES NOT have any basic reading, writing or math skills
No basic reading, writing or math skills
Veteran
No Iraqi Freedom Desert Storm Vietnam Other
Confidential Demographics
HIV/AIDS Battered Spouse Ex-Offender Drug Dependant Troubled Youth Alcohol Dependant Homeless
Work Status
Unknown Part-time Full-time Full-time (minimum wage) Unemployed Unemployed, Temp. Medical Disability Unemployed, Perm. Medical Disability Unemployed Seeking employment Unemployed Seeking entitlements Self-Employed Seasonal Worker Labor Force (Daily Work) Non-Labor Force (Child/Elderly/Disabled) Student (Full-Time 18+) Retired Other Farmer Migrant Farmer Seasonal Farmer
Employment Skill Status
No Marketable Skills Limited Skills (Employment Barrier) Moderate Marketable Skills In Demand Skill Set (Advancement) Unknown
Income Sources
Income Type
Recurring Income (Future): $
Period:
Type a question
Prior Months Income $
January
February
March
April
May
June
July
August
September
October
November
December
Receive any of the following?
Health Benefits Financial Benefits Life Insurance
Should be Empty:

	Prior Months Income $
January
February
March
April
May
June
July
August
September
October
November
December