Individual Financial Assistance Request Application

APPLICANTS QUALIFY ONLY IF THEIR ANNUAL GROSS INCOME IS:

Single Filed: < $75,000
Head of Household: < $112,500
Married Filed Joint: < $150,000

Financial Assistance Request Application - County of Maverick

Name of Applicant

First

Last

Date of Birth

Last 4 of SS#

Address

City

State/Province

Zip/Postal

Country

Phone

Secondary Phone

Number of Adults Over 65 In Home:

Number of Adults In Home:

Number of Children In Home:

Claimant #1

Date of Birth:

Last 4 of SS#

Claimant #2

Date of Birth:

Last 4 of SS#

Claimant #3

Date of Birth:

Last 4 of SS#

Claimant #4

Date of Birth:

Last 4 of SS#

Claimant #5

Date of Birth:

Last 4 of SS#

Claimant #6

Date of Birth:

Last 4 of SS#

Did you receive any compensation from assistance programs? If so, please list date, program, and amount received: (Federal Grant, Stimulus, Loan, SNAP, TANF, etc.)

Reason for request: (How has COVID-19 affected you or your family, financially?)

Financial Needs: (How would this financial assistance address your needs?)

Proof of Income (Income Tax Return Statement or Income Tax Transcript)

Maximum upload size: 33.55MB

Identification

Maximum upload size: 33.55MB

Proof of Residence

Maximum upload size: 33.55MB

Signature

Clear

I am over the age of 18 years and I have personal knowledge of the facts contained herein, and they are true and correct. If it is later found that the information that I have provided is not correct I understand that I may be required to repay any and all benefits that I received or were paid on my behalf.

Individual Financial Assistance Request Application

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