General Assistance Questionaire

* Required fields. These questions MUST be answered

Name *

Address *

Best number to reach by phone *

How many children do you have? *
  Please enter a numeric value. Enter 0 for no children.
Ages of Children *
Please enter ages separated by comma (e.g. 5,8,10) or a range (e.g. 5-10)
Employer / If not employed, please explain why. *

Hours worked per week *


Monthly Income
Please answer all that apply to your family.

Wages

SSI

TANIF

SS

Food Stamps

Disability

Child Support

Unemployment

Veterans

Other

Monthly Expenses--Please List Below *

What Kind of Assistance do you need? *

Please answer the following question--How did you get behind in your payment and what is your plan to prevent this in the future? *

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