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- 1 - GENERAL ASSISTANCE/RELIEF ADDENDUM Please circle the answer to the following questions: 1. Have you lived in a county other than Douglas in the last six YES NO months? (verification will be required if you application is accepted) 2. Are you a student? YES NO 3. Have you quit a job within the last 60 days? YES NO 4. Have you been fired from a job within the last 60 days? YES NO 5. Is your vehicle worth more than $4,000? YES NO 6. Do you own more than one vehicle? YES NO 7. Do you own an ATV, boat, snowmobile, or camper? YES NO 8. Are you currently sanctioned from Food Stamps or W-2? YES NO 9. Do you have stocks, bonds, or savings certificates? YES NO 10. Have you received General Assistance within the last 4 months? YES NO 11. Do you have minor children in the household? If so, have you applied for assistance through Work Force Connections at the Job Center? (this will be verified if your application is accepted) YES NO 12. Are you receiving rental assistance or public housing? YES NO If you answered YES to any question from #1-12, you will not be eligible. You may still complete an application and turn it in to receive a denial notice. If you answered NO to #11, you need to get a denial notice from them to be eligible for General Assistance, along with the other eligibility criteria. By signing below, I certify that the answers to the questions above are true and accurate to the best of my knowledge. I understand that giving false information may result in a denial of assistance through this program. Signature Today’s date ---PAGE BREAK--- - 2 - APPLICATION FOR GENERAL RELIEF 1. First Middle Last Maiden 2. Street/RFD Room/Apt # City, State Zip 3. If in rural area, directions to 4. Telephone 5. Prior Application(s) for assistance here:______Yes_____No If yes, 6. Anyone in home receiving assistance?________Yes________No Type of 7. Persons for whom assistance is requested: Full Name Relationship Date of Birth Place of Birth Social Security # 8. Others in the home (names and relationship to 9. Military Service: Name Rank Entered Date Discharged Type ---PAGE BREAK--- - 3 - 10. Employment Record – Last 5 years: Name Employer Gross Wages From/To Reason for Termination Regular Occupation or 11. Marital Record – Last 5 years: Of Whom To Whom Place Date Death/Divorce/ Separated Place Date 12. Current and Former Addresses – Last 5 years: Address City, State, Zip From/To ---PAGE BREAK--- - 4 - 13. Registered for Unemployment Compensation Benefits? If yes, Where? Length of penalty period, if When 1st check is expected?________ 14. Are you presently attending school? Yes No If yes, where? 15. Actively seeking employment? Yes No 16. Registered with WI State Employment Service? Yes No If yes, when? What success? 17. Purchase of automobile, refrigerator, TV set, snowmobile, or any major item within the last six months? Yes No If yes, what? When? 18. Balance due on above 19. Does applicant farm? Yes No If yes, what is the cash crop? 20. Amount of farm income for the past three 21. Any purchase or sale of livestock, hay, etc., in the past 6 months?___Yes ___No If yes, what? 22. Any purchase or sale of farm equipment in past six months? ____Yes If yes, what? 23. Does anyone in household have life insurance? Yes No If yes, complete: Insured’s Name Name of Company Date Issued Face Value Case Value 24. Health, hospital, or accident insurance? Yes No If yes, name of company: 25. Do you own a house, trailer, property or co-own any? Yes No If yes, what? Where? With whom? ---PAGE BREAK--- - 5 - 26. Income in household: Income in Household Yes No Who Amount Social Security Veteran Benefits Railroad Retirement Workmen’s Compensation weekly Unemployment weekly Rent money received Interest or Dividends Crop and/or other farm income Money from a relative Room & Board Alimony or support Welfare checks List kinds and amounts of other types of income such as annuities, other retirement plans, 27. Liquid Assets: Liquid Assets Yes No Who Amount Cash on Hand or at home Saving Account(s) Checking Account(s) Savings Certificate(s) Automobile (year & make) Bonds Stocks List kinds and value of other resources: ---PAGE BREAK--- - 6 - 28. In case of emergency – please contact: Name and Relationship Address Phone Name and Relationship Address Phone 29. Receipt of cash other than from employment during the last three months? If yes, 30. If you have a cemetery lot, where is it 31. Living arrangements: I rent a house I rent a trailer I rent an apartment I live in public housing I am buying a home I am buying a trailer 32. I also pay for utilities, heat, gas for cooking. Amount Amount Amount 33. Landlord’s Name and Address Date Rent Due 34. Put and in each box to show that you understand these statements. I certify that the information on this application is a true and complete state- ment of facts according to my best knowledge and belief. I also understand that giving false information may subject me to prosecution for fraud. I understand the need for and agree to let the Agency know of any changes in my household income or resources within ten (10) days and to report with- in ten (10) days any change in household conditions that might affect my eligibility. Failure to do so may subject me to prosecution for fraud. I further understand that I may be required to work off the value of relief received. I also understand that the work must be completed within the month or no further assistance will be granted. The only exception will be if your physician states, in writing, that you are unable to work. Signature Date