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Jim Hogg County CARES Coronavirus Aid, Relief, and Economic Security Act Emergency Household Assistance Program
Household Information
Head of Household Name
*
Email Address
*
Address
*
City
*
State
*
Zip
*
Phone
*
Date of Birth
*
+
What Assistance Are You Seeking?
*
1. Rent
2. Mortgage
Housing Type
*
1. Own
2. Rent
3. Other Permanent Housing
4. Homeless
5. Other
6. Unknown/Not Reported
If you Own, Mortgage/Month
*
+
If you Rent, Mortgage/Month
*
+
Anybody in the Household Receives
*
1. Income from Employment
2. Workers Compensation
3. Pension
4. Child Support
5. VA Service Disability Compensation
6. SNAP
7. Housing Voucher
8. HUDVASH
Anybody in the Household Receives
*
1. Income from Employment
2. Workers Compensation
3. Pension
4. Child Support
5. VA Service Disability Compensation
6. SNAP
7. Housing Voucher
8. HUDVASH
Residential Information
Address
*
City
*
State
*
Zip
*
County
*
Household Information
Total Number of Family Members, Including You:
*
1
2
3
4
5
6
7
8
9
10
11
12
Please include complete names of Household Members including Date of Birth
*
Comments
Please Include Any Comments That Will Help Explain Your Situation, If Any
Upload Documents
Identification for All Adults in the Household: State Issued ID Card
*
Proof of Hardship Unemployment or Furloughed Letter or Check Stubs Noting Decrease of Hours or Wages or Letter from Employer Showing Reduction in Hours/Wages Due to COVID-19
*
Proof of Income Check Stubs (past 30 days) or SNAP Verification or TANF Card or SSI/SSDI Award Letter or Pay History from Employer (Layoff/Reduction of Hours) or Proof of Unemployment Payments (TWC)
*
Proof of Household Size Tax Return with all Household Members Listed
*
Lease Agreement or Mortgage Statement Copy of Lease Agreement Signed by all Parties or Mortgage Statement or Notice of Delinquency from Landlord or Mortgage Company
*
Medical Issues Proof of Inability to Work Due to COVID-19 and Current Medication Prescriptions
*
Client Signature
By signing, I acknowledge that I have uploaded all necessary documents. I understand that the submission of an application does not guarantee that I will receive services. I understand that I may have to appear for an interview, if needed. I also authorize Jim Hogg County to release and/or obtain information necessary to determine eligibility.
*
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