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? *

Housing Type *

If you Own, Mortgage/Month * +

If you Rent, Mortgage/Month * +

Anybody in the Household Receives *

Residential Information

Address *

City *

State *

Zip *

County *

Household Information

Total Number of Family Members, Including You: *

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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