U.S. Government Support Programs Template

Question Title

* 1. Have you ever applied for Medicare benefits, or not?

Yes, I have

No, I have not

Question Title

* 2. Has anyone in your household ever applied for Medicare benefits, or not?

Yes, someone has

No, no one has

Not sure

Question Title

* 3. Do you currently receive Medicare benefits, or not?

Yes, I do

No, I do not

Question Title

* 4. Does anyone in your household currently receive Medicare benefits, or not?

Yes, someone does

No, no one does

Question Title

* 5. Do you currently receive food stamps, or not?

Yes, I do

No, I do not

Question Title

* 6. Does anyone in your household currently receive food stamps, or not?

Yes, someone does

No, no one does