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
Name of Applicant
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
Maximum upload size: 33.55MB
Maximum upload size: 33.55MB
Maximum upload size: 33.55MB
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.
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