How do I fill out the Communications Preference Form?

The purpose of this form is for our agency to confirm which is the preferred language of the household so we may communicate in that manner for spoken or written communication. This form must be filled out entirely so we can update our records and make sure all communication received is in the language chosen. You can choose multiple languages and this form is only filled out by the head of household.

You must fill out the following:

• Name: the full name of the head of household.
• Last four digits of the SSN: last four digits of the social security number of the head of household.
• Address: the full contract unit the family is staying in.
• Question 1: This is to select the primary spoken language for the household.
• Question 2: This is to select the primary written language for the household.
• Question 3: This is asking if the household will need translation/interpretation services through our agency. You must select ‘YES’ or ‘NO’.
• Signature line: the signature of the head of household.
• Date line: the date when the form was signed.