1. General Information
Previous Three Addresses (including city and state)
My family and I have lived:
I am now asking for assistance for myself and the following members of my family, who reside with me.
In addition to those listed above, the following relatives, boarders, lodgers and other persons, for whom I am not seeking assistance, are living in the same house.
I understand that if I want someone else to apply for General Assistance for me, and I am mentally and physically able to apply, I must provide a written statement giving that person permission to apply on my behalf.
The statement must include the full name, address, and telephone number of the person applying for me. The statement must also say that I remain responsible for the information provided and liable for repayment of benefits received due to incorrect or incomplete information.
This application must be signed by the applicant. If the applicant is too ill or otherwise mentally or physically unable to complete the application, it may be filed by a spouse, parent, child, adult sibling, other relative, or another person able to furnish the necessary information.
I have read this application for General Assistance and declare under penalties of perjury that the information supplied in this application and all accompanying statements is true and correct and constitutes a complete statement of all income, assets, and resources belonging to me or any member of my immediate family.
I agree to notify the Supervisor of General Assistance of any change in need, resources, income, or assets. I authorize any person, bank, firm, corporation, transfer agent, agency, institution, or the Department of Human Services to furnish information requested by the Supervisor of General Assistance.
I hereby make application for General Assistance on behalf of the person named below and certify that, to the best of my knowledge and belief, the information furnished herein is a true statement of his/her income, assets, and resources.
