General Assistance Application (Page 7 of 8) in pdf

OTHER INFORMATION:

Have you applied anywhere else for assistance in the last 6 months? Yes____ No____

If yes, where and determination? ________________________________________________________________

If you have not lived at your present address for at least one full consecutive year, list your previous addresses and the dates you lived

there:

__________________________________________________________________________________________

________________________________________________________________

AUTHORIZATION SIGNATURE / AGREEMENT TO REPAY:

I understand that by signing this Agreement to Re-pay, and accepting any relief assistance from Jackson County General Relief

Department that I may be required to repay the full amount of any assistance granted, if or when I am able to do so, and that failure

to do so shall result in denial of future assistance.

I understand that giving false information in this application and/or to the General Assistance staff is unlawful, can be considered

fraud and may be referred to the Jackson County Attorney for court action. It may also result in my becoming permanently ineligible

for future assistance. Also, giving false information on this application or to the General Assistance staff, or refusing to provide

requested information, may result in denial of assistance and being ineligible for more assistance for one (1) year.

I understand that according to the Code of Iowa, my estate may be subject to recovery by the county for assistance granted. I further

understand that my homestead may be subject to recovery by the county for assistance granted in if there is no surviving spouse or

child as defined in Section 234.1.

Do Not Sign!

Signature(s) must be notarized or signed in presence of General Assistance Director or Intake Officer!

_________________________________________________________________________________________

(Signature of Applicant)

Date

_________________________________________________________________________________________

(Signature of Co-Applicant)

Date

_______________________________________________________________________________________________________________

(Signature of Director or Intake Officer)

Date

STATE OF IOWA, COUNTY OF ______________________

Signed and sworn before me, on this ________ day of _________________________, 20_____,

by ___________________________________________________________________________

Name(s) of Persons

Notarized by: _____________________________________________________, Notary Public

Print Name: ___________________________________

(Seal)

My commission expires: _______________________

FOR OFFICE USE ONLY

____ Resident

____ Non-Resident (county of residency?):__________________________________

____ Poor

____ Needy

(County of Legal Settlement?)____________________________________

____ Approved _____Denied

See back of page! Page 7 of 8

General Assistance Application Page 7

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