Subsidy, Resource & Referral Program 
PRELIMINARY APPLICATION 
 
 
 
 
 
 
 
                                                        No.: ____ 
 
NAME OF APPLICANT:  _______________________________________  FAMILY SIZE: _______ 
 
SS#________________________(required)_________________Single_______________Married 
 
MAILING ADDRESS: ___________________________________________________________ 
 
 
 
        _________________________________________________________ 
 
EMAIL ADDRESS:       _________________________________________________________ 
 
TELEPHONE NOS.: ____________________         _________________   ________________ 
                                              WORK                                         CELL                             HOME 
 
PLACE OF EMPLOYMENT: _______________________________Phone#________________ 
 
SCHOOL OR TRAINING PROGRAM: _____________________________________________ 
 
 
ARE YOU A TEEN PARENT?             YES          NO 
 
ANNUAL INCOME: $_____________   CHILD SUPPORT INCOME: $_______________ 
 
NAME OF CHILD (REN) ________________ 
_________   DOB: _______________ 
 
 
 
 
______________________ 
__    DOB: ________________ 
 
 
 
 
________________________       _    DOB: ________________ 
 
 
______________________ 
 
 
 
 
__________________ 
    Signature of Applicant 
 
 
 
 
 
 Date 
 
 
Official use only 
 
[ ] ELIGIBILITY   [ ] COMPLETED   [ ] NO LONGER INTERESTED   [ ] NO SHOW   [ ] OTHER 
 
[ ] INELIGIBILITY   [ ] INSUFFICIENT HOURS   [ ] NOT IN COMPONENT  [ ] OVER QUALIFIED     
If you are found eligible, you will be placed on the waiting list upon the availability of funds; however, if you are ineligible you will 
be notified. 
Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930  
3129 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 772-7147