Form W-680FF (page 1 of 2) LLF

Rev. 7/25/16

064 DeKalb Job Center Date: 02/02/2021

275 Bergen St, 1st Fl Case Number: 00038287680D

Brooklyn NY 11217

ROBERT HOOMAN
63 PEARL ST
Apt 124
BROOKLYN NY 11201-1147

Language Questionnaire
IMPORTANT: Please read this notice and indicate your speaking and reading language preferences. If you do not speak English well, the
Human Resources Administration (HRA) can provide free interpreter services for you at an HRA office. This form must be completed and
returned with the application/recertification papers.

Print Name: ROBERT HOOMAN

Name M.I. Last Name

Address: 63 PEARL ST
Apt 124

City: BROOKLYN State: NY Zip: 11201-1147

Do you need a sign language interpreter? c

d
e
f
g Yes c
d
e
f
g No

What is your preferred spoken language? Please select ONE only.

b English
c
d
e
f
g

g African Languages
c
d
e
f g Armenian
c
d
e
f g Creole – Haitian
c
d
e
f g Hindi
c
d
e
f
c Alaskan
d
e
f
g c Assyrian
d
e
f
g c Creole – Other
d
e
f
g c Hmong
d
e
f
g
c Albanian
d
e
f
g c Bengali
d
e
f
g c Croatian
d
e
f
g c Hungarian
d
e
f
g
c American Indian – Apache
d
e
f
g c Bosnian
d
e
f
g c Czech
d
e
f
g c Ilocono
d
e
f
g
c American Indian – Choctaw
d
e
f
g c Bulgarian
d
e
f
g c Dutch
d
e
f
g c Indonesian
d
e
f
g
c American Indian – Crow
d
e
f
g c Burmese
d
e
f
g c Dzongkha
d
e
f
g c Italian
d
e
f
g
c American Indian – Dakota
d
e
f
g c Cambodian
d
e
f
g c Farsi
d
e
f
g c Japanese
d
e
f
g
c American Indian – Lokota
d
e
f
g c Chamorro
d
e
f
g c Finnish
d
e
f
g c Karen
d
e
f
g
c American Indian – Nakota
d
e
f
g c Chinese – Cantonese
d
e
f
g c French
d
e
f
g c Khmer
d
e
f
g
c American Indian – Navajo
d
e
f
g c Chinese – Fujian
d
e
f
g c French – Creole
d
e
f
g c Kinyarwanda
d
e
f
g
c American Indian – Other
d
e
f
g c Chinese – Mandarin
d
e
f
g c German
d
e
f
g c Kirundi (Rundi)
d
e
f
g
c American Indian – Zuni
d
e
f
g c Chinese – Other
d
e
f
g c Greek
d
e
f
g c Kizigna
d
e
f
g
c Amharic
d
e
f
g c Chinese – Toisanese
d
e
f
g c Gujarati
d
e
f
g
c Arabic
d
e
f
g c Creole – Criollo
d
e
f
g c Hebrew
d
e
f
g

(Additional languages are continued on the next page.)

Include in CA Application/Recertification Kits and

NCA SNAP Application/Recertification Kit
Form W-680FF (page 2 of 2) LLF Human Resources Administration
Rev. 7/25/16 Family Independence Administration

g Korean
c
d
e
f g Onondaga
c
d
e
f g Serbian
c
d
e
f g Tigrinya
c
d
e
f
c Kurdish
d
e
f
g c Oromo
d
e
f
g c Serbo-Croation
d
e
f
g c Tona – Seneca
d
e
f
g
c Laotian
d
e
f
g c Pashto
d
e
f
g c Shinnecock
d
e
f
g c Tongan
d
e
f
g
c Lithuanian
d
e
f
g c Pennsylvania Dutch
d
e
f
g c Sign Language
d
e
f
g c Turkish
d
e
f
g
c Maay
d
e
f
g c Persian
d
e
f
g c Slovak
d
e
f
g c Tuscarora
d
e
f
g
c Macedonian
d
e
f
g c Pidgin – Hawaiian
d
e
f
g c Somali
d
e
f
g c Twi (Fanti)
d
e
f
g
c Malayalam
d
e
f
g c Polish
d
e
f
g c Spanish
d
e
f
g c Ukranian
d
e
f
g
c Mohawk (St. Regis Tribe)
d
e
f
g c Portuguese
d
e
f
g c Swahili
d
e
f
g c Unkechauga
d
e
f
g
c Mongolian
d
e
f
g c Punjabi
d
e
f
g c Swedish
d
e
f
g c Urdu
d
e
f
g
c Native American
d
e
f
g c Romanian
d
e
f
g c Syriac
d
e
f
g c Vietnamese
d
e
f
g
c Nepali
d
e
f
g c Russian
d
e
f
g c Tagalog
d
e
f
g c Yiddish
d
e
f
g
c Norwegian
d
e
f
g c Samoan
d
e
f
g c Thai
d
e
f
g c Yugoslavian
d
e
f
g
c Oneida
d
e
f
g c Seneca
d
e
f
g

Do you require free interpreter services? c Yes g

d
e
f
g b No
c
d
e
f

Written notices can be sent in the languages listed below. Please select only ONE. If your preferred language is not listed, please check (þ)
English.

g Arabic
c
d
e
f c Creole – Haitian
d
e
f
g c Russian
d
e
f
g b English
c
d
e
f
g
c Chinese
d
e
f
g g Korean
c
d
e
f g Spanish
c
d
e
f

02/02/2021
Applicant's/Participant's Signature Date

Include in CA Application/Recertification Kits and

NCA SNAP Application/Recertification Kit