Community Services General Assistance Pre-Screen Form

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 highlighted in red.

1. First Name
2. Last Name
3. Address
4. City
5. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. Zip Code
7. Phone
8. Email
9. Date of Birth
10. Type of Assistance Requested: Please Select Rent Utility Medication Burial
11. Names of Household Members/Ages
12. Are all household members U.S. Citizens? Please Select Yes No

Net Household Income This Past Month

13. Job Income:
14. Social Security/SSI:
15. FIP:
16. Child Support/Alimony:
17. Unemployment:
18. Worker's Comp:
19. Food Stamps:
20. Total Household Income:

Miscellaneous

21. Do you receive Section 8, HUD, SIRHA? Please Select Yes No
22. How much rent do you pay each month?
23. Landlord/Apartment Name:
24. Are any adult household members a student? Please Select Yes No
25. Have any household members served in the Military? Please Select Yes No
26. If served in the Military, is this person Service Connected? Please Select Yes No
27. Have any household members voluntarily quit or get fired from job in the last 90 days? Please Select Yes No
28. Are you applying for Social Security: Please Select Yes No
29. Current Doctor:
30. Have you ever been denied at the Administrative Law Judge Level (ALJ) in the Social Security process? Please Select Yes No
31. If so, when did this occur?

Tax Information

32. Taxes Filed: Please Select Yes No
33. Tax Return Received: Please Select Yes No
34. Date:
35. Amount:
36. Used For?

Reason for Assistance

37. Please list why assistance is needed.
38. Comments:

Key Services & Resources