COUNTY GENERAL ASSISTANCE APPLICATION

STANTON COUNTY GENERAL ASSISTANCE APPLICATION

Date:

I agree to give all information and verification needed to determine my eligibility.

Full Name:

Last

First

M.I.

Maiden

Birth Date:

Social Security No.

Name Spouse:

Last

First

M.I.

Maiden

Last

Birth Date:

Social Security No.

Birth Date:

Marital Status (circle one): S M W D

Date of Divorce/Separation:

Are you a U.S. Citizen: Yes / No

Registered Alien: Yes / No

Date Registered:

Telephone No.:

Current Address:

Street/Rural Address

Mailing (PO Box)

Town

Zip Code

How long have you lived at your current address:

Years

Months

Number of Children:

List all Persons, including yourself, in your Household:

Name

Birth Date

Relationship

List Previous Addresses where you have lived within the past year:

Dates

Are you self-employed: Yes / No

Type of Work Done

Name and Address of last two jobs done and the dates completed:

Place of Employment:

Address:

How Long Employed There:

List Employment History starting with Current or Last Job:

	Employer		Address				From/To						Reason Terminated

1.

2.

3.

4.

5.

6.

If unemployed, are you registered at the job service: Yes / No								If Yes, Date registered:

Is your spouse registered at the job service: Yes / No								If Yes, Date registered:

List 5 places and their addresses where you/your spouse have applied for employment:

1.											Date
		Employer’s Response to Application:

2.											Date
		Employer’s Response to Application:

3.											Date
		Employer’s Response to Application:

4.												Date
		Employer’s Response to Application:

5.												Date
		Employer’s Response to Application:

Are you a Veteran: Yes / No				In War Time: Yes / No

Is your spouse a Veteran: Yes / No					In War Time: Yes / No

If Yes, has the Veterans Administration helped you in the past year: Yes / No												Date


INCOME:						AMOUNTS
Source						Self			Spouse					Family/Other
Salary - Employment
Payment Type – weekly / bi-weekly / monthly / bi-monthly						$				$					$
Child Support						$				$					$
Alimony						$				$					$
Social Security						$				$					$
Supplemental Security Income (SSI)						$				$					$
Retirement Income – (type)						$				$					$
Veterans Pension						$				$					$
Union Payments						$				$					$
Unemployment Compensation						$				$					$
Workmen’s Compensation						$				$					$
Charitable Organizations						$				$					$
Food Stamps						$				$					$
Veterans Administration Assistance						$				$					$
Self-Employment						$				$					$
Vocational Rehabilitation						$				$					$
Rentals						$				$					$
Boarders						$				$					$
Friends/Relatives						$				$					$
Other						$				$					$

Date – Amount – source of last check:

Income – How Spent:

ITEM

AMOUNT

ITEM

AMOUNT

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

___________________

____________

RESOURCES:

I own my own home: Yes / No

I own other property: Yes / No

I have owned a house, farmland, or other property: Yes / No

What happened to the property you did own:

Check “Yes” or "No” to each of the below and give the dollar amount:

Checking Account #

Yes / No

Savings Account #

Yes / No

Cash on Hand

Yes / No

Safety Deposit Box

Yes / No

Certificate of Deposit

Yes / No

Stocks or Bonds

Yes / No

Farm Crops

Yes / No

Livestock

Yes / No

Farm Machinery

Yes / No

Car , Truck - Make

Year

Model

Yes / No

2^nd Vehicle - Make

Year

Model

Yes / No

Other - Make

Year

Model

Yes / No

Other - Make

Year

Model

Yes / No

Mobile Home-Make

Year

Model

Yes / No

Life Insurance – Names of Company

Yes / No

Policy No.

Does it have Cash value

Yes / No

Does it have Cash value

Yes / No

Other

Yes / No

Do you have Health Insurance:

Yes / No

Name of Company/Address

Policy No.

Does any household member own property: Yes / No

Does any household member any Cars, Trucks, Boats, RV’s, Mobile home, Motorcycles: Yes / No

Year

Make

Model

Have you ever applied for SSI: Yes / No

Medicaid: Yes / No

Do you have any special medical problems which you feel are related to your financial ability to pay:

In case of emergency, notify:

Name:

Relationship:

Address:

Telephone:

What would you currently like help with - medication, bills, etc. (please attach a copy of each bill, etc.):

AUTHORIZATION for RELEASE of INFORMATION

Name:

Address:

Birth Date:

Social Security Number:

I authorize the release of information (see attached) to the Stanton County Clerk.

Applicant’s Signature

Date

Witness Signature

Date

YOU HAVE THE RIGHT

To expect your application to be accepted and acted upon promptly within thirty (30) days from application for continuing assistance and within seven (7) days for application for short-term assistance.

To appeal and ask for a fair hearing if you are not satisfied with the action taken on your application.

To be assisted in various aspects of application or determination of eligibility by the person of your choice.

To have confidential treatment of private information.

To have program requirements and benefits fully explained.

To know that you can be required to reimburse any assistance obtained through misrepresentation or fraud or any interim assistance issued pending a determination of eligibility for any supplemental security income program or other categorical assistance program which provides retroactive benefits or pending the issuance of a lost or stolen warrant.

To know that the County may request reimbursement for County Medical Assistance from legally responsible parties if they are of sufficient ability to repay.

SIGNATURES

Under penalties of law, I declare that I have read this form, including accompanying statement and to the best of my knowledge, it is true, correct and complete. I understand my responsibilities and agree to fulfill them. I agree to provide proof of need if requested, and I give consent for the agency to make whatever contacts are necessary to determine my eligibility, and I hereby authorize release of financial or medical information and understand that my signature below constitutes such a release.

I have had the assistance programs and program requirements explained to me and I do ( ) do not ( ) wish to received assistance based on these requirements.

NOTE: If someone helped you fill out this form, be sure that the person signs below.

Signature of Applicant

Date

Signature of Applicant’s Spouse

Date

Return to:

Stanton Co Clerk

PO Box 347

Stanton 68779

Signature of Person who completed form if not Applicant

Address of Person who assisted