Application For State Emergency Relief Page 2
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1
2
3Case Name
Case Number
Specialist
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
Supplemental Security Income (SSI)
Self-employment income
Worker’s Compensation
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
Heat
Yes
No
Yes
No
$
Electricity
Yes
No
Yes
No
$
Yes
No
Yes
No
Water/sewer
$
Cooking fuel
Yes
No
Yes
No
$
Rent
$
Mortgage
$
Property Taxes
$
Home insurance
$
HOUSEHOLD INFORMATION FOR THE PAST SIX MONTHS
Complete the chart below to tell us about your expenses, income and how many people live with you for the last six (6) months. If you did not have the expense,
write “NONE” in the box.
1 MONTH AGO
2 MONTHS AGO
3 MONTHS AGO
4 MONTHS AGO
5 MONTHS AGO
6 MONTHS AGO
Month
# of people in home
Total monthly income
$
$
$
$
$
$
Rent/Mortgage amount
$
$
$
$
$
$
Heat
$
$
$
$
$
$
Electricity
$
$
$
$
$
$
Water, Sewer & Cooking
$
$
$
$
$
$
Gas
Yes → Check all that apply and ATTACH PROOF.
-
INCOME EXPENSES
Does your household pay any of the following?
No
Health insurance premium $
Paid how often?
Covers what time period (1mo., 3 mos., etc.)
$
Court ordered child support (amount paid per month)
Actual child care costs paid by the employed person, not DHS
Unusual employment related expenses $
Explain expense
DHS-1514 (Rev. 9-13) Previous edition obsolete. MS Word
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