General Assistance Application (Page 4 of 8) in pdf

EMPLOYMENT INFORMATION:

Employed? Yes___ No___ Name of employer:______________________________________________________

Address: ____________________________________________________________________________________

If not employed, why?___________________________________________________________________________

If not employed, date of last employment?______________________________

Employer?____________________________________________________________________________________

Are you or anyone in the household disabled? ___Yes ___ No

Who and when was determination of disability?______________________________________________________

Reason for leaving employment? Health ___

Quit ___ Laid-off ___ Seasonal Work____ Terminated ___ Business Closed ___

Other Reason ___ Explain: __________________________________________________________________

Is your spouse employed? Yes____ No____ If yes, where?________________________________________________

If not, why?__________________________________________________________________________________

Any other members of the household 18 years of age or over employed? Yes____ No____

Where?______________________________________________________________________________________

If not, why?__________________________________________________________________________________

If not employed, are you or other family members registered with Iowa Workforce?

Yes____ No____ Where are you/they registered?________________________________ You must show proof.

HEALTH INFORMATION:

If you cannot work because of health reasons, are you willing to provide a physicians note? ___ Yes ___No

Does anyone in the household have medical coverage? Yes____ No_____

Title XIX (Medicaid): _____

Medicare: _____

Private insurance: _____

Other: _____

If yes, what type _________________ Through who? __________________________ Company ______________________

HOUSING INFORMATION:

Do you own your home?

Yes____ No____

Are you buying it? Yes____ No____

Do you rent? Yes____ No____

Landlord name?________________________________________ Landlord Phone #: (____) -______-______

Landlord Address:______________________________________________________________________________

Street

City

State

Zip

Is the landlord related to any of the household members in ANY way? (parent, child, aunt/uncle, grandparent, boyfriend/girlfriend,

spouse/fiancé )

Yes____ No____

If yes, give relationship: ________________________________________________________________________________

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General Assistance Application Page 4