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The form also requires providing Social Security Number(s) as required by federal law or applying for them through the Social Security Administration.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What does the optional Section 2 collect and how is it used?",{"text":114,"@type":110},"Section 2 collects sexual orientation and gender identity information. 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Information provided is subject to verification.  \nNOTE: Retain your copy of your completed application. Regarding your Social Security Number, it is mandatory that you provide your Social Security Number(s) as required in 42 USC 405, or that you apply for a Social Security Number(s) with the Social Security Administration. This information will be used in eligibility determination and coordinating information with other public agencies.  \n\n| Date of Application: | Case Number (if known): |\n| --- | --- |\n\nSection 1 – Personal Information  \n\n| Name of Applicant: |  |  | Social Security Number: |\n| --- | --- | --- | --- |\n| Street Address: |  |  | City: |\n| State: | Zip Code: | Telephone: |  |\n|  |  | Email: |  |\n| Date of Birth: |  | Sex:  Male  Female |  |\n\nSection 2 – Sexual Orientation and Gender Identity (Optional)  \nProviding responses in the sections below is optional and confidential. Any information you provide in this section will not be used in your eligibility determination.  \n\n| What is your gender identity?\u003Cbr>(check the box that best describes your current gender identity) |  |\n| --- | --- |\n| 􀂅 Female\u003Cbr>􀂅 Male\u003Cbr>􀂅 Transgender: male to female\u003Cbr>􀂅 Transgender: female to male | 􀂅 Non-Binary (neither male nor female)\u003Cbr>􀂅 Another gender identity\u003Cbr>􀂅 Decline to state |\n\nSOC 295 (9/18) Page 1 of 8  \n\n| What sex was listed on your original birth certificate?  |  | Female |  | Male |\n| --- | --- | --- | --- | --- |\n| How do you describe your sexual orientation?\u003Cbr>Select one answer. |  |  |  |  |\n| 􀂅 Straight/heterosexual\u003Cbr>􀂅 Gay or lesbian\u003Cbr>􀂅 Bisexual\u003Cbr>􀂅 Queer | 􀂅 Another sexual orientation\u003Cbr>􀂅 Unknown\u003Cbr>􀂅 Decline to state |  |  |  |\n\nSection 3 – Veteran Information  \n\n| Are you a Veteran?\u003Cbr> Yes  No | Are you a Spouse/Child of a Veteran?\u003Cbr> Yes  No |\n| --- | --- |\n| If YES, give Veteran name and Claim Number: |  |\n\nSection 4 – SSI/SSP Information  \n\n| Do you receive SSI/SSP benefits?  Yes |  | No |\n| --- | --- | --- |\n| If yes, check your type of living arrangement:\u003Cbr> Independent Living  Board and Care  Home of Another |  |  |\n| Services being requested: |  |  |\n\nSection 5 – Past IHSS Information  \n\n| Have you received In-Home Supportive Services (IHSS) in the past? |  |  | Yes  No |\n| --- | --- | --- | --- |\n| If Yes, complete the following.\u003Cbr>Date and county where service was last received: |  |  |  |\n| Total Monthly Hours: | Name Used (if different from above): |  |  |\n\nSection 6 – Household Information  \nList Household Members:  \n\n| Name of Spouse: |  |\n| --- | --- |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n| Name of:  Parent  Child  Other Relative  Non-Relative |  |\n| Birthdate: | Social Security Number: |\n\nSection 7 – Ethnic and Language Information  \nThe law requires that information on ethnic origin and primary language be collected. If you do not complete this section, social service staff will make a determination. The information will not affect your eligibility for service.  \n\n| A. My Ethnic Origin is:\u003Cbr>(See Page 8 for a list of Ethnicities and Codes)\u003Cbr>Please choose one | B1 . What language do you prefer to read?\u003Cbr>B2 . What language do you prefer to speak?\u003Cbr>(Please choose one from the list of Languages and Codes on Page 8)\u003Cbr>Please choose one\u003Cbr>Please choose one |\n| --- | --- |\n\nSOC 295 (9/18) Page 3 of 8  \nSection 8 – Communication Accommodations  \nTo accommodate blind or visua","cbCaip6PW0ZbiGvj","https://ap.wps.com/l/cbCaip6PW0ZbiGvj","pdf",915819,8,"English","# Application Information\n## Section 1 – Personal Information\n## Section 2 – Sexual Orientation and Gender Identity (Optional)\n## Section 3 – Veteran Information\n## Section 4 – SSI/SSP Information\n## Section 5 – Past IHSS Information\n## Section 6 – Household Information\n## Section 7 – Ethnic and Language Information\n## Section 8 – Communication Accommodations","[{\"question\":\"What information is required when completing the SOC 295 application?\",\"answer\":\"All sections must be completed, and information provided is subject to verification. The form also requires providing Social Security Number(s) as required by federal law or applying for them through the Social Security Administration.\"},{\"question\":\"What does the optional Section 2 collect and how is it used?\",\"answer\":\"Section 2 collects sexual orientation and gender identity information. Responses are optional and confidential and are not used in the eligibility determination.\"},{\"question\":\"How does the form handle communication accommodations for blind or visually impaired applicants?\",\"answer\":\"Section 8 asks whether the applicant is blind or visually impaired and then indicates preferred accommodation formats for specific DSS document types, including options such as Braille, Audio CD, Data CD, and other support types.\"}]","APPLICATION FOR IN-HOME SUPPORTIVE SERVICES - SOC 295 - Application form | PDF",1789836035]