General Assistance Application Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8INCOME: Have you or has anyone in your household applied for, or received, any of the following sources of income in the last 8
weeks? For each applicable source of income, please indicate “yes”, “no” or “applied for,” along with the monthly net amount
received.
APPLIED FOR IN
MONTHLY NET
SOURCE:
NO
YES
(MONTH/YEAR)
AMOUNT
Employment
Unemployment / Workers Comp
Self-Employment
Pension
Child Support / Alimony
Interest / Dividends
SSI or Social Security Disability
FIP (ADC / ADC-UP)
Food Assistance including EBT
Rent or Utility Assistance
Student Loans / Grants
Rent Paid to you
Inheritance / Estate
Cash from friends or family
Any other income
TOTAL HOUSEHOLD INCOME
ASSETS:
Do you own, or are you buying, your home, a farm, any land or real estate building, or property? ____ Yes ____ No
If yes, what specifically? ________________________________________________________________________
What is the current fair market value? _____________________ How much do you still owe? _________________
Do you, or anyone in your household, have any of the following:
ITEM:
NO
YES
VALUE
Cash on hand
Checking Account
Savings Account
Life Insurance with cash value
CD’s or IRA’s
Stocks or bonds
Burial trusts / contracts
Guns or firearms
Antiques or Collectables
Jewelry (besides wedding rings)
Farm Equipment
Livestock
Machinery, tools, or equipment
Any other asset
TOTAL VALUE OF ASSETS
List all motor vehicle: including cars, trucks, motorcycles, recreational vehicles, boats, etc.
Year
Type
Make
Fair Market Value
Amount Owed
See back of page! Page 5 of 8
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal