Attachment "A"
Print out this worksheet, and list the name of each member of the household, the relationship from the list below, the age, and if the household member is included in the "household."
| Applicant |
Grandfather |
Niece |
| Aunt |
Grandmother |
Other |
| Brother |
Grandson |
Sister |
| Cousin |
Great-Grandfather |
Son |
| Daughter |
Great-Grandmother |
Stepdaughter |
| Father |
Husband |
Stepson |
| First cousin, once removed |
Mother |
Uncle |
| Grand daughter |
Nephew |
Wife |
| Relationship |
Name |
Age |
Included in
"Household"? |
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Based on the following definition, is the applicant a caretaker relative? Yes / No - Circle One
Caretaker Relative – Relative within the 5th degree of kinship primarily responsible for the care
of a minor child. Relationship may be by blood, adoption, or marriage.
"5th degree of kinship" includes brothers, sisters, aunts, uncles, grandparents, cousins, great grandparents, great aunt or uncle, first cousin once removed, etc.
A relative cannot qualify as a child’s “caretaker relative” if the parent of that child is in the home.
Legal guardianship is not required.