Food Stamp  Worksheet
Brought to you by your friends at Crossroads Urban Center and SLCAP

Income Hourly wage Average Hours a week 1st earner*   * 2nd earner       Total Other  income (unearned FEP, SSI, GA, Social Security etc.)

Enter Childrens Ages and Child Care costs per month Child1 Age  Cost  Child2 Age  Cost  Child3 Age  Cost  Child4 Age  Cost  Child5 Age  Cost  Child6 Age  Cost  Child7 Age  Cost  Child8 Age  Cost  Child9 Age  Cost  Child10 Age Cost

Out of Pocket Medical Costs ($35 will be taken)	Rent/Mortgage costs
Fire Insurance (if any)	Property Tax (if any)
Utility Costs Use $229 unless there are no out of pocket costs	Total # people in household*
Child Support Costs	Elderly or Disabled Person in household

* Required field

Utah Online Food Stamp Application