Fillable Household Assistance Application (City of Beaumont)

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Household Assistance Application (City of Beaumont)

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The Household Assistance Application (City of Beaumont) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Applicant Name:
Current Address:
Phone Number:
From To Yes No Name Number
Member's Full Name Date of Birth Age
How did you hear about this program?
What is the combined total monthly income of all household members over the age of 18?
Fill in the Monthly Total line using calculations specified below.
Make sure all income sources are listed below and employer name is complete for every member of the household over the age of 18.
Monthly Total (add all income sources listed below):
Household Member's Full Name
Employer Name and/or
Other Source(s) of
Income
Current Monthly
Income Before Taxes
Email Address:
APPLICATION FOR HOUSEHOLD ASSISTANCE
Landlord (if Applicable)
Rental
Household Composition (List head of household and all other members of the household. Provide the relationship of each member to the head of household):
Relationship to Head of Household
Total number of people living in the household:
List Place(s) of Residence Since January 1, 2020:
Address
Use the last thirty days income to calculate the averge current monthly income, including wages, salaries and tips; other income like alimony, child support; and unemployment, Social Security, AFDC or other benefits.
Last Date Worked if Unemployed
If family assistance is received, how often and how much?
TOTAL MONTHLY INCOME
City of Beaumont - COVID-19 Pandemic Relief Program
SELF DECLARATION OF INCOME
RESIDENCY
Name Address
Household Member's Full Name Layoff Furlough Reduced Hours Lost Wages
Head of Household Signature Date:
Co-Applicant Signature(s) (All other household members over the age of 18 for which benefits are to be calculated) Date:
Application Checklist:
Completed application with wet signatures
All Documents/Evidence to Support Information Provided by the Applicant on the Grant Application
Verification from employer showing reduction in hours, layoff notice, termination letter, unemployment filling, etc.
Copy of a 2019 Income Tax Return for all persons age 18 and older for which income is considered
Completed W-9 for Head of Household
Details
I and all other parties 18 years of age and older understand that the above information is being collected to determine whether I/we are eligible to receive household assistance. I have read the foregoing City of Beaumont Household
Assistance Grant Application and understand the questions and requirements. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I acknowledge that the completion of this
application does not in any way indicate eligibility or approval. I acknowledge that, due to the limited funds available for the program, some qualifying applications including this one may not be funded. The City of Beaumont is hereby
authorized to verify all information provided with this application.
ADDIONAL DOCUMENTATION
APPLICATION CERTIFICATION:
CURRENT EMPLOYMENT INFORMATION
Household Member's Full Name
Which, if any, of the above household members had layoff, furlough, reduced hours or lost wages related to COVID-19? Please list below the employer and other relevant information as well as providing written confirmation from
the employer.
If you are self-employed, please include the name of the business and bank statements from a prior period showing self-employment income and statements from current period showing loss of income with explanation below:
Dates Employed
Job Title
Contact Name and Number for Employment Verification
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Household Assistance Application (City of Beaumont)

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Completed 14 January 2021

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