Application For State Emergency Relief - Dhs-1514 Page 2
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4Case Name
Case Number
Specialist
Yes ATTACH PROOF OF CURRENT VALUE
-
HOUSEHOLD VEHICLE(S)
Does your household have any vehicles?
No
Car
Truck
Boat
Camper/trailer
Motorcycle
RV
Other vehicle
Name(s) on Title or Registration
Make and Model
Year
Fair Market Value
Amount Owed
Yes ATTACH PROOF OF CURRENT VALUE
-
HOUSEHOLD ASSETS
Does your household have any assets or joint accounts?
No
Cash
Money market accounts
Savings bonds, stocks or mutual funds
Patient trust fund
Checking account
Christmas club accounts
Land contact, mortgage or other note
Burial plot(s), casket, etc.
Savings account
Life Estate
payable to household member
Burial trust/funeral contract(s)
Credit union account
Life insurance
Tools and equipment, livestock or crops
Real estate
Certificate of deposit (CD)
OTHER (list)
IRA, KEOUGH, 401K or Deferred Comp. account(s)
Expect money from a lawsuit in the next 30 days
Owner(s) of asset(s)
Type(s) of asset(s)
Balance amount or value
Name of bank, insurance company, etc.
Account/policy number
$
$
$
*Please tell us if anyone has closed any accounts, sold or given away property, a vehicle, stocks, bonds, etc. How long ago?
Yes
No
*Has anyone filed a lawsuit or expect money in the next 30 days?
If yes, Explain
Yes Total monthly household income $
-
HOUSEHOLD INCOME
Does your household have any income?
No
Please check all sources of income that your household expects to receive in the next 30 days. ATTACH PROOF
Social Security benefits
Disability benefits
Employment/earned income
Worker’s Compensation
Supplemental Security Income (SSI)
Self-employment income
Pension/retirement benefits
Unemployment
Money from family/friends
Veteran’s benefits/Military allotments
Child support
Other, please list (ex: lottery winnings)
Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)
Rental income or a land contract, mortgage or other payment payable to a household member
Type of Income
Gross Monthly Income
Person With Income
How often received?
(if employed, name of employer)
(amount before any expenses or taxes)
*Please tell us if there have been any changes or if you expect a change in your household income in the next 30 days.
When did or will this change occur?
CURRENT HOUSING EXPENSES
Check all expenses
Monthly
Name of your service provider,
Is this a shared
Is there theft or
Name and address on
Account number
you are required to pay
Expense
landlord, mortgage company, etc.
meter?
illegal use?
bill or account
Yes
No
Heat
Yes
No
$
Yes
No
Yes
No
Electricity
$
Water/sewer
Yes
No
Yes
No
$
Cooking fuel
Yes
No
Yes
No
$
Rent
$
Mortgage
$
Property Taxes
$
Home insurance
$
DHS-1514 (Rev. 11-15) Previous edition obsolete.
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Parent category: Medical