Fillable County General Assistance Application for COVID-19 Relief (Madison County Government)

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County General Assistance Application for COVID-19 Relief (Madison County Government)

On average this form takes 29 minutes to complete

The County General Assistance Application for COVID-19 Relief (Madison County Government) form is 2 pages long and contains:

  • 1 signature
  • 19 check-boxes
  • 102 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Madison County Government

BROWSE MADISON COUNTY GOVERNMENT (NC) FORMS

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County General Assistance Application for COVID-19 Relief
Name: ________________________________ SSN: _______________ DOB: _________
Address: ____________________________________________________ Mailing Address:
_______________________________________ Phone (Home/Cell):_________________
Email Address: ______________________________________ Okay to use for written correspondence
Other Household Members Information:
Name:
SSN:
DOB:
Children: In school?
Most recent employment: ________________________________________ Title: _______________
Employer Phone Number: _______________________ Manager’s Name: __________________
Hours worked/week: ______ Hourly wage (w/tips):______ Last Day of Employment_________________
Income: Income:
Type
Amount
Frequency
Earned Income
Earned Income
Child Support
Work First
Unemployment
Social Security
SSI
Other
Total Household Income: $____________ Received Stimulus Check (Y/N):______ Amount: $_________
Reserves:
Cash:
Savings:
Stocks/Bonds:
Property Equity:
Total Reserves: $______________
Entitlement Program Enrollment:
FNS/SNAP:
Utility Allowance:
Medicaid (MAGI):
Adult Medicaid:
Assistance received due to COVID19: _____________________________________________________
Type
Amount
Frequency
Earned Income
Earned Income
Child Support
Work First
Unemployment
Social Security
SSI
Other
Housing Situation: Own Rent Employer Subsidize Homeless Other:__________________
Current rent/mortgage (w/o utilities): $__________ List utilities included: _________________________
Please describe how the COVID-19 crisis has affected you and/or your household.___________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Immediate need: Rent/Mortgage Electric Water Telephone Internet Other_____________
Amount Requesting: $_________
Vendors Name: ______________________ Address: __________________________________________
Account Number: __________________________ CIN#:________ Phone #:________________________
Other related information: _______________________________________________________________
Secondary need: Rent/Mortgage Electric Water Telephone Internet Other_____________
Amount Requesting: $_________
Vendors Name: ______________________ Address: __________________________________________
Account Number: __________________________ CIN#:________ Phone #:________________________
Other related information: _______________________________________________________________
By signing this I am certifying that the information I have provided is true and complete to the best of
my knowledge. I understand that funding is limited and is not guaranteed. I give the Madison County
Department of Social Services permission to verify information as it deems necessary to determine
eligibility and to communicate with the vendor about my eligibility for this service and to coordinate the
payment.
_
Signature Date
Verbally authorization given by phone in lieu of signature
Intake completed by: _________________________
Funds Requested: $_______________ Funds Awarded: $_______________ Date Approved: _________
Date Denied: ___________ Reason for denial: _______________________________________________
Funds Sent to: ________________________________________ Date Funds were sent: ______________
How Funds were sent: __________________ Confirmation Number: __________________
Funds Sent to: ________________________________________ Date Funds were sent: ______________
How Funds were sent: ___________________ Confirmation Number: ________________________
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County General Assistance Application for COVID-19 Relief (Madison County Government)

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Completed 18 July 2020

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