SUSSEX COUNTY DIVISION OF SOCIAL SERVICES INQUIRY SHEET Date:________________________________ Inquiry #________________(office use) Name : _____________________________ Mailing Address:_____________________ Phone:______________________________ _____________________________________ Municipality:_______________________ _____________________________________ Marital Status:__________ Age:______ Residence:___________________________ Name of Spouse (if applicable): ____________________________________ Age:_________________________________ Names and Ages of Children:___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Names of Other Household Members (relationship):______________________________ ______________________________________________________________________________ Earned Income (Gross):________________________________________________________ ______________________________________________________________________________ Unearned Income (Gross):______________________________________________________ ______________________________________________________________________________ Type:______________________________________ Amount:___________________________ Property/Real Estate: ________________________________________________________ Bank Accounts/Savings/Cash Available:_________________________________________ ______________________________________________________________________________ Vehicles:_____________________________________________________________________ How Can We Help You? _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SEND TO: Mail: E-Mail: Fax: Sussex County Div. of cwa.scdss@xbp.dhs.state.nj.us 973-383-3627 Social Services PO Box 218/83 Spring Street Newton, NJ 07860 1D (Rev. 11/11)