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Pottawattamie County Emergency Drinking Water Distribution Site

Burn Ban Issued for Portions of Pottawattamie County Amid Water Supply Concerns

Level RED Drinking Water Advisory for Regional Water Rural Water Association Customers

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General Assistance

General Assistance Pre-Screen Form

Please complete the following form to learn more about opportunities for General Assistance.

Please read the overview of General Assistance in Pottawattamie County before submitting this pre-screen form. You'll find information on assistance that is and is not provided.

Pre-Screen Form

Required fields are marked with an asterisk (*).

First Name *
Last Name *
Address *
City *
State *
Zip Code *

Phone *
Email *
Date of Birth *
Type of Assistance Requested: *
Names of Household Members/Ages *
Are all household members U.S. Citizens? *

Net Household Income This Past Month

Job Income:
Social Security/SSI:
FIP:
Child Support/Alimony:
Unemployment:
Worker's Comp:
Food Stamps:
Total Household Income:

Miscellaneous

Do you receive Section 8, HUD, SIRHA? *
How much rent do you pay each month? *
Landlord/Apartment Name: *
Are any adult household members a student? *
Have any household members served in the Military? *
If served in the Military, is this person Service Connected? *
Have any household members voluntarily quit or get fired from job in the last 90 days? *
Are you applying for Social Security: *
Current Doctor:
Have you ever been denied at the Administrative Law Judge Level (ALJ) in the Social Security process? *
If so, when did this occur?

Tax Information

Taxes Filed: *
Tax Return Received: *
Date:
Amount:
Used For?

Reason for Assistance

Please list why assistance is needed. *
Comments: *

Community Services

Advocate Information Crisis General Assistance Southwest Iowa Mental Health & Disability Services Region FAQ Department Home

227 S 6th St.
Council Bluffs, IA 51501
(712) 328-5600

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