Application for General Assistance Funding, Authorization for Release of Information & Information Required for General Assistance Funding

Application for General Assistance Funding, Authorization for Release of Information & Information Required for General Assistance Funding

Before beginning this application, please be sure to have all of your required documents ready to upload. Applications submitted without all required documents will not be considered complete. - If you are filling this application out on a phone, or tablet, please be sure that you utilize the scroll option on the tables to ensure all information requested is input.
APPLICATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your marital status?*

MarriedWidowedDivorcedSeparatedNever MarriedDomestic PartnerCommon LawOther
What is your gender?*

MaleFemaleOther
What is your ethnicity?*

HispanicNon-Hispanic
What is your race?*

WhiteBlack / African AmericanAmerican Indian / Alaska NativeAsianNative Hawaiian / Other Pacific IslanderAnother Single RaceMore than One Race

	Yes	No
Is anyone in the household currently pregnant?
Is everyone in the household a US citizen or a documented resident?
Has anyone in the household ever served in the military?
Does anyone in the household have Veteran Status?
Does anyone in the household need mental health support?
Is anyone in the household currently in recovery for substance misuse?
Is anyone in the household court involved?
Are you or any adults in the household a student?
Does anyone in the household have Life Insurance
Does anyone in the household have Burial and other Insurance
Do you have Health / Hospital Insurance

Social Determinants of Health Screening Tool*

	Yes	No
In the past year, did you ever eat less than you felt you should because there wasn't enough money for food?
Do you have concerns about your current living situation? (housing conditions, safety, costs, homelessness)
Do you have trouble paying your utility bills? (gas, water, electric, phone, propane)
In the past year, have you ever had to go without something you needed because you didn't have a way to get there?
Are you afraid that you might be hurt by someone in your home?
Do problems getting childcare make it difficult for you to work or study?
During the last four weeks, have you been actively looking for work?
Do you often feel lonely or isolated from those around you?
Is there anyone in your household without health or dental insurance?
In the past year, was there a time when you needed to see a doctor but could not because of the cost?
In the past year have you used alcohol, recreational drugs, or a prescription medication for non-medical reasons?
Does your household have the need for a Family Support Program?
Do you have any other needs that you would like help with?
Would you like Warren County Health Navigation to follow up with you on any concerns that you have indicated in this section?

Are you or your household working with any of the following agencies currently, or have worked with any of the following agencies in the most recent 12-months?*

	Currently	In the most recent 12-months	No
Warren County Health Navigation
WeLIFT Job Search Center
WeLIFT Navigation
IMPACT Community Action Program
Aging Resources of Central Iowa
Salvation Army
Indianola Hope Foundation
Norwalk Area Ministerial Association
Indianola Methodist Church
Local Church
Warren County Housing Authority
Warren County Veteran Affairs
SHIP - SMP
Iowa Legal Aid
Children and Families of Iowa
Other

List EVERYONE (Including yourself) in your Household for whom you are applying for assistance:*

	First Name	Last Name	Date of Birth	Last 4 of SSN	Schooling Completed	Relationship to Applicant	Occupation
Yourself
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9

Date you moved into your current address:*

MonthDayYear
Date
If you rent, how much rent are you paying:
What utility companies are in your name?*
Landlord / Property Manager:
Name
Landlord / Property Manager Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord / Property Manager Email:
example@example.com
Landlord / Property Manager Phone Number:
Please enter a valid phone number.

Does ANYONE in your HOUSEHOLD have any of the following resources?*

	Yes	No	Amount	Name/Names of Person on Account
Checking Account
Checking Account 2
Checking Account 3
Savings Account
Savings Account 2
Savings Account 3
Venmo
PayPal
Chime
Cash App
Apple Pay
Direct Express

List ALL sources of HOUSEHOLD income available to you, your spouse, dependent(s), and / of others living in the household. *

	Yes	No	Amount	How Often is Income Received	Name of Person Receiving Income
Social Security (SSI, SSDI, Retirement Benefits, etc.)
Social Security 2
Social Security 3
Social Security 4
Veteran's Benefits
Soldiers Relief
Earnings (Wages)
Earnings 2
Earnings 3
Earnings 4
Unemployment
FIP
SNAP Benefits
Child Support
Foster Care Income
Other

Employment history for ALL HOUSEHOLD members for the last year

	Employee	Employer	Employer Address (City)	Kind of Work	Date Began	Date Ended	Hourly Wage	Reason for Discontinuing
Most Recent or Current Employment
Most Recent or Current Employment 2
Most Recent or Current Employment 3
Most Recent of Current Employment 4
Previous Employment
Previous Employment 2
Previous Employment 3
Previous Employment 4
Previous Employment 5
Previous Employment 6
Previous Employment 7

Are you currently receiving a Section 8 Voucher, or income based housing:*

YesNo
What type of financial assistance are you requesting:*

RentUtilityTransportationPrescription MedicationMedicalEssential NeedsOther
YOUR SIGNATURE IS ALSO AN AUTHORIZATION FOR THIS OFFICE TO OBTAIN VERIFICATION OF FACTS GIVEN ON THIS FORM. I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I FURTHER UNDERSTAND THAT I MAY BE LEGALLY PROSECUTED FOR INTENTIONALLY MAKING FALSE STATEMENTS IN ORDER TO RECEIVE ASSISTANCE. Public Record Disclosure Notice Please be advised that applications for Health Navigation and/or General Assistance are subject to review and approval by the Warren County Board of Supervisors/Warren County Board of Health . As part of this process, your first and last initials may appear on public records, including meeting agendas and minutes, in accordance with Iowa Open Records laws. These records may include references to assistance claims requiring board approval. By submitting this application, you acknowledge and understand that limited personal identifiers (i.e., initials) may be included in publicly available documents related to your request for assistance. Please be advised that applications for Health Navigation and/or General Assistance are subject to review and approval by the Warren County Board of Supervisors/Warren County Board of Health . As part of this process, your first and last initials may appear on public records, including meeting agendas and minutes, in accordance with Iowa Open Records laws. These records may include references to assistance claims requiring board approval. *

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If you are dissatisfied with the action of this office, you may appeal to the Warren County Board of Supervisors, Court House, Indianola, Iowa.

PROHIBITION AGAINST DISCRIMINATION
We will consider this application without regard to race, color, sex, age, handicap, religion, national origin, or political belief.
If you feel you have been the object of such discrimination, you may file a complaint in letter form with the Warren County Board of Supervisors, Administration Building, Indianola, Iowa.

CONFIDENTIALITY
All applicants and/or recipients have the right to confidential treatment of information concerning their situation; however, it should be understood that such information may be shared with other employees of Warren County, including the Warren County Board of Supervisors. A certain amount of information may need to be released to direct providers of service, such as pharmacies, hospitals, doctors, landlords, utility providers, etc., in order to authorize release of goods to the client. In certain instances when the General Relief employee is working cooperatively with other agencies, i.e., Veterans Affairs, Community Action Center, and/or County department, certain information may be released in order to complete transactions.
AUTHORIZATION FOR RELEASE OF INFOMATION
Authorization for Release of Information - I voluntarily allow information to be exchanged between Warren County General Relief and the following agencies/organizations for the coordination of services:*

Utility ProvidersLandlord / Property ManagerFuneral HomePharmacyMedical ProviderCurrent and Previous EmployersChild Support Recovery UnitWarren County Veteran's AffairsIMPACT Community Action PartnershipIowa Vocational Rehabilitation ServicesIowa Workforce DevelopmentWeLift Job Search CenterSalvation Army of Central IowaAging Resources of Central IowaIndianola Hope FoundationMinisterial Fund AllocatorsWarren County Health NavigationIowa Legal AidIowa Community HubRolling Hills Central Iowa Shelter & ServicesWarren County Housing AuthorityDepartment of Health and Human ServicesChildren and Families of IowaIowa MedicaidSNAPMedicareSHIP & SMPInsurance ConsultantSocial Security AdministrationWarren County Health ServicesWarren County Attorney's OfficeMental Health ProviderSubstance Use ReferralEducational InstitutionOther
I voluntarily allow Warren County General Assistance to communicate with me:*

Electronically by the email providedTo call the number providedTo leave a voicemail at the phone number providedTo text the number provided
Authorization for Release of Information form allows the Warren County General Assistance office to gather additional verification of information provided and or advocate on your behalf for additional services.*

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Acknowledgement of Job Policy

*Per Warren County Codes and Ordinance: Policies and Administration, Chapter 3.04 General Eligibility:
By signing, you understand and agree to the policy in place referenced above. It is understood that to qualify for any additional months of assistance, you must be working 20 or more hours per week. If you are not working 20 or more hours per week, you agree to provide confirmation of at least 8 job applications submitted in the prior 30 days before receiving any additional month of assistance. You also agree to let us check with any of the employers you have listed, verifying your contact.*

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Have you received Warren County General Assistance in the past:*

YesNo
If you have received Warren County General Assistance in the past, are you and all adults in the household working 20 or more hours per week?

YesNo
If you or other adults in the household are not working 20 or more hours per week, please continue to confirm the 8 job applications that you have subnitted in the last 30 days.

Confirmation of 8 applications to jobs in the last 30 days.
Job searches can be completed online, in person, and through WeLift Job Search Center.
•Online applications: Require documentation of the actual job search emails.
•In person applications: May be verified by General Assistance.
•WeLift Job Search Center: Offers 1 on 1 job coaching, resume building, interviewing practice, connections to additional resources,and a computer lab. All services are free thanks to all their donors. WeLift can provide a signature that an application is completed.
If you have applied for assistance in the past, and have an adult in the household that is not working 20 or more hours per week, please continue to confirm the 8 job applications that have submitted in the last 30 days. - Upload confirmation of 8 applications to jobs in the last 30 days here.

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INFORMATION REQUIRED FOR GENERAL ASSISTANCE FUNDING

Please provide us with the following for EVERYONE IN THE HOUSEHOLD. If this section left incomplete, then your application will not be considered for approval.
Please upload copies of ID's for all adult members of the household here.*

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Please upload copies of Social Security Cards for all members of the household here.*

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PROOF OF INCOME FOR THE MOST RECENT 30 DAYS (Pay stubs, Social Security Benefit Award Letter, Employer’s Written Statement, Work Comp Statements, Child Support, Foster Care Income, FIP, Veterans Benefits, etc. for everyone in the household).
- If you cannot work, please provide a current Report of Incapacity Form filled out by your physician.
- If you have had no income in the most recent 30 days, you must obtain a WHITE SHEET from Iowa Workforce Development, located at 200 Army Post Road, Des Moines, Iowa 50315. Phone: 515.281.9619.
- Per Warren County Codes and Ordinance: Title I – Policies and Administration, Chapter 3.04 General Eligibility;
  - If your household has applied for assistance before, and is requesting assistance again, all adults need to work 20 or more hours per week. Adults not working 20 or more hours per week will need to provide confirmation of at minimum 8 job applications submitted in the most recent 30 days.
*INCOME ELIGIBILITY CRITERIA
- 200% Gross Income = $2,510 One Person Household ($897 for each additional family member). Subject to change, at the direction of the Warren County Board of Supervisors.
*WE MUST HAVE ALL THE REQUIRED INFORMATION BEFORE WE ARE ABLE TO ASSIST. IF YOU PROVIDE FALSE INFORMATION TO RECEIVE BENEFITS, YOU WILL NOT BE ELIGIBLE FOR ASSISTANCE FROM OUR OFFICE FOR THREE (3) YEARS FROM THE DATE OF APPLICATION.
Please upload your household's proof of income for the most recent 30 days here. (See descriptions from previous screen)*

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DOCUMENTATION OF ALL MONEY TRANSACTIONS FOR THE MOST RECENT 30 DAYS (ALL Checking/Savings/Venmo/Cash App/Chime/Apple Pay/Pay Pal/Etc. And All Cash Transactions for everyone in the household ).

*WE MUST HAVE ALL THE REQUIRED INFORMATION BEFORE WE ARE ABLE TO ASSIST. IF YOU PROVIDE FALSE INFORMATION TO RECEIVE BENEFITS, YOU WILL NOT BE ELIGIBLE FOR ASSISTANCE FROM OUR OFFICE FOR THREE (3) YEARS FROM THE DATE OF APPLICATION.
Please upload all household money transactions form the most recent 30 days here. (See descriptions from previous screen)*

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FOR RENTAL ASSISTANCE
- A copy of your LEASE OR RENTAL AGREEMENT.
*ELIGIBILITY CRITERIA
- Must be renting, & not receiving a Section 8 Voucher or HUD subsidized housing.
- Everyone listed on your application for General Assistance must be listed on the lease or rental agreement.
- Landlord or Property Management must fill out & submit a Rental Verification Form.
*WE MUST HAVE ALL THE REQUIRED INFORMATION BEFORE WE ARE ABLE TO ASSIST. IF YOU PROVIDE FALSE INFORMATION TO RECEIVE BENEFITS, YOU WILL NOT BE ELIGIBLE FOR ASSISTANCE FROM OUR OFFICE FOR THREE (3) YEARS FROM THE DATE OF APPLICATION.
Please upload a copy of you lease of rental agreement here. (See descriptions from previous screen)

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FOR UTILITY ASSISTANCE
- A copy of the most recent UTILITY BILL & DISCONNECT NOTICE.
ELIGIBILITY CRITERIA
- The utility bill must be in the name of the applicant for General Assistance.
- Must have made “good faith” effort payment(s) during the moratorium (Nov. – March).
*WE MUST HAVE ALL THE REQUIRED INFORMATION BEFORE WE ARE ABLE TO ASSIST. IF YOU PROVIDE FALSE INFORMATION TO RECEIVE BENEFITS, YOU WILL NOT BE ELIGIBLE FOR ASSISTANCE FROM OUR OFFICE FOR THREE (3) YEARS FROM THE DATE OF APPLICATION.
For utility assistance, please upload a copy of the most recent utility bill or disconnect notice here. (See descriptions from previous screen)

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Application for General Assistance Funding, Authorization for Release of Information & Information Required for General Assistance Funding

APPLICATION

AUTHORIZATION FOR RELEASE OF INFOMATION

Acknowledgement of Job Policy

INFORMATION REQUIRED FOR GENERAL ASSISTANCE FUNDING