Prc/fset Application

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PRC/FSET Application
Prevention, Retention and Contingency/ Food Stamp Employment & Training Program
For Agency Use Only
Present Address
Name of Applicant
Case Number
Social Security Number
Date Sent
Date Returned
Telephone Number Where You Can Be Reached
County
Unique ID
Yes
No
1. Have you ever received any type of public assistance from a human services department?
If yes, give the county, the type of assistance received and the date received.
2. Explain what you need and estimate the amount you are requesting.
3. Has anyone in your household quit or refused a job in the past 90 days?
Yes
No
If yes, give name of employer, the date of the quit or refusal and the reason for the quit or refusal.
4. Complete the chart below for anyone living in your home, including yourself. You are required to verify
all income for all members of your household.
Relationship to Applicant
Monthly Amount of Income
Name
Age
Source of Income
*
If you need additional space please attach another sheet.
*If you are eligible, the agency will limit assistance under this program to the actual documented amount of need.
Signature of Applicant
Date

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