Northeast Iowa Counties Cpc/community Services Howard County Cpc Application Form Page 3
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5NOTICE: Proof of income may be required with this application including but not limited to pay-stubs, tax-returns, etc.
If you have reported no income above, how do you pay your bills? (Do not leave blank if no income is reported!)
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Gross Monthly Income (before taxes):
Applicant
Others in Household
(Check Type & fill in amount)
Amount:
Amount:
Social Security
SSDI
SSI
.
Veteran’s Benefits
Employment Wages
FIP
Child Support
Rental Income
Dividends, Interest, Etc
Pension
Other
Total Monthly Income:
Household Resources: (Check and fill in amount and location):
Type
Amount
Bank, Trustee, or Company
Cash
Checking Account
Savings Account
Certificates of Deposit
Trust Funds
Stocks and Bonds (cash value?)
Burial Fund/Life Ins (cash value?).
Retirement Funds (cash value?)
Other _____________________
______________________
___________________________________________
Other_____________________
______________________
___________________________________________
Total Resources:
Motor Vehicles:
Yes
No
Make & Year: ___________________
Estimated value:__________ _______________
(include car, truck, motorcycle, boat,
Make & Year: ___________________
Estimated value:__________ _______________
Recreational vehicle, etc.)
Make & Year: ___________________
Estimated value:_________________________
Make & Year:___________________
Estimated value:__________________________
Do you, your spouse or dependent children own or have interest in the following:
House including the one you live in
Any other real-estate or land
Other_________________________________
If yes to any of the above, please explain: _________________________________________________________________
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Have you sold or given away any property in the last five (5) years?
Yes
No If yes, what did you sell or give away?
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Legal Settlement: Legal Settlement is the term used to determine what county will provide funding for requested services. This
is determined by a person residing twelve consecutive months (six months for persons considered legally blind) within a county without
receiving treatment and/or other support type services, including prescription medications, for Mental Health, Mental Retardation,
Developmental Disabilities, Brain Injury, Substance Abuse and/or Jail or imprisonment. Please complete the following information in
its entirety as much as possible to assist us in determining your county of legal settlement. If you need more space, you may copy the
following sheet and/or use another sheet of paper to provide this information.
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