General Assistance Application
Applications & Permits · 6 pages · 2,028 words · all documents · the town's PDF →
Town/City of:____________________________________________________________ 03/17/2025
APPLICATION FOR GENERAL ASSISTANCE
Administrator: Please read the following to the applicant or have the applicant read it in your presence.
PENALTY FOR FALSE REPRESENTATION. Whoever knowingly and willfully makes any false representation of a material fact to the overseer of any municipality or to the department or its agents for the purpose of causing that or any other person to be granted assistance by the municipality or by the State is guilty of a Class E crime and shall reimburse the municipality for that assistance. Further assistance may be denied until that person reimburses the municipality for the assistance or enters into a written agreement, which must be reasonable under the circumstances, to reimburse the municipality or that person has been ineligible for assistance for a period of 120 days, whichever period is longer. (22 M.R.S.A. § 4315).
1. HOUSEHOLD (Please type or print) Name of Applicant: Date of Birth: Social Security Number: Household size: (Total people in household)
Mailing Address: Number of people seeking assistance: Physical Address:
Telephone number: Applicant
Marital Status:
Most recent previous address:
Single
Previous GA application When? Where?
YES NO Married
made?
Separated
Is anyone in the household currently disqualified When? Reason for
from receiving GA? YES NO disqualification? Divorced
If yes, who? Widowed
SOCIAL Able Bodied (A)
PEOPLE LIVING IN THE RELATIONSHIP DATE OF BIRTH BIRTHPLACE SECURITY Disabled (D)
HOUSEHOLD
NUMBER Minor (M) Vet. (V)
2. HOUSEHOLD INFORMATION
Does everyone in the Does everyone in the Has your household Have you reached Is anyone
household receive household have Maine applied for LIHEAP? the TANF 60 sanctioned by
SNAP benefits? Care? month time limit? TANF?
YES NO YES NO YES NO YES NO YES NO
Does anyone in the Did you or anyone in Has your household filed an Do you have subsidized housing?
household have a your household serve in income tax return? YES NO
warrant for their arrest the U.S. Military? YES NO
as a result of a felony YES NO If yes, list date If yes, list your
conviction? and amount: monthly amount:
Has anyone applied for Has anyone received an income Has anyone received a lump sum?
YES NO a VA Pension? tax refund? Date: Date:
no Amount: Amount:
Is everyone in the household a U.S. Citizen? Is any other person, or agency assisting with your household
YES NO expenses (rent, electric, heat etc.)? If yes, please explain:
NOTE: If any household member does not have permanent
status, affidavit must be completed.NAMES AND ADDRESSES OF EMERGENCY CONTACTS WHO ARE NOT IN THE HOUSEHOLD (PARENTS, GRANDPARENTS AND ADULT CHILDREN WHO ARE NOT MEMBERS OF THE HOUSEHOLD)
1. Name: 2. Name:
Mailing Address: Mailing Address:
Relationship: Telephone #: Relationship: Telephone #:
3. EMPLOYMENT INFORMATION – APPLICANT
Section 3-A Complete section 3-A if one or more members of your household are employed.
Currently employed household member #1: Currently employed household member #2:
Name: Name:
Elvira
Employer: Employer:
Date of last paycheck: Date of last paycheck:
Amount of last paycheck: Amount of last paycheck:
Date of next paycheck: Date of next paycheck:
Additional Comments:
Section 3-B Complete section 3-B if one or more members of your household are able to work but are unemployed.
Able-Bodied unemployed household member #1: Able-Bodied unemployed household member #2:
Name: Name:
Joe
Previous Employer #1: Previous Employer #1:
Reason Job Ended: Reason Job Ended:
Last Date of Employment: Last Date of Employment:
Previous Employer #2: Previous Employer #2:
Reason Job Ended: Reason Job Ended:
Last Date of Employment: Last Date of Employment:
Highest Level of Education Completed: Highest level of Education Completed:
Additional Comments:
Section 3-C Complete section 3-C if one or more members of your household are unable to work for medical reasons.
Disabled unemployed household member #1: Disabled unemployed household member #2:
Name: Name:
Disability preventing work? YES NO Disability preventing work? YES NO
Medical statement verifying? YES NO Medical statement verifying? YES NO
Active SSI/SSDI application? YES NO Active SSI/SSDI application? YES NO
Completed IAR on file? YES NO Completed IAR on file? YES NO
Do you have an attorney? YES NO Do you have an attorney? YES NO
What stage are you at in your What stage are you at in your
application for SSI?SSDI? application for SSI?SSDI?
Additional Comments:
4. ASSISTANCE REQUESTED
ASSISTANCE REQUESTED: Please list each type of assistance being requested and enter the amount of the request.
ASSISTANCE AMOUNT ASSISTANCE AMOUNT
1. Food $ $
7. Household/Personal Supplies
2. Rent $ 8. Prescriptions/Medical $
3. Mortgage $ 9. Water $
4. Electricity $ 10. Sewer $
5. LP Gas $ 11. Other (Specify): $
6. Heating Fuel $ TOTAL ASSISTANCE REQUESTED $ 0.00
5. USE OF INCOME - REPEAT APPLICANTS ONLY - PRIOR 30 DAYS (Office use only)
Income: $
$
$
Total: (A) $ 0.00
Household Receipts Other Receipts
Food $ Phone $
Housing $ Internet $
Electricity $ Cable/Subscription Services $
Propane $ Alcohol/Tobacco $
Heating Fuel $ Restaurants/Entertainment $
Household $ Vacations/Travel $
Personal $ Pet Food $
Prescriptions/Medical $ Fines/Bails $
Water $ Other: $
Sewer $ $
Other: $ Total: (C) $ 0.00
$
Total Income: (A)
$ 0.00
$
Total: Less Household Receipts: (B)
$ 0.00
(B) $ 0.00
Notes: Total Other Receipts: (C)
(Misspent Money) $ 0.00
D. Unaccounted Money
(A)-(B)-(C) $ 0.00
E. Total of (C + D)
Misspent + Unaccounted $
(Added to Line O, section 6):
0.006. PROJECTED 30 DAY INCOME
INCOME: Enter the amount of all money to be received (in the next 30 days) by: (1) the applicant; (2) the applicant’s family; and (3) unrelated household members. Report how often income is received. MONEY APPLICANT MONEY FAMILY MONEY OTHERS OFFICE RECEIVES RECEIVES RECEIVE USE ONLY TYPE OF INCOME MONTHLY AMOUNT FREQUENCY AMOUNT FREQUENCY AMOUNT FREQUENCY TOTAL
A. Employment $ $ $ $ 0.00
B. TANF $ $ $ $ 0.00
C. SSI – Supplemental
Security Income $ $ $ $ 0.00
D. State Supplement
($10 if receive SSI) $ $ $ $ 0.00
E. Social Security
(other) $ $ $ $ 0.00
F. Unemployment or
Workers Comp $ $ $ $ 0.00
G. Military/Veteran
Benefits $ $ $ $ 0.00
H. Retirement or
Pension Plan $ $ $ $ 0.00
I. Child/Spousal
Support $ $ $ $ 0.00
J. Bank Accounts and
0.00
Cash On Hand $ $ $ $
K. Income In Kind $ $ $ $ 0.00
L. Post-Secondary
financial aid, grants $ $ $ $ 0.00
M. Other (please $ $ $ $ 0.00
specify)
For Repeat Applicants Only:
N. Investment Asset(s) Value (See Section 7, C) $ 0.00
O. Misspent Income & Unverified Expenditures (during the last 30 days) (See Section 5, Line E) $ 0.00
SUBTOTAL – MONTHLY HOUSEHOLD INCOME $ 0.00
P LESS: Total verified monthly work-related expenses: Child Care: $________ Mileage: (RT miles ____* # of
days a week: ____* # of weeks per month: ______* ordinance mileage:_____ )=_________ Other: __________
0.00 $ 0.00
TOTAL – MONTHLY HOUSEHOLD INCOME $ 0.007. ASSETS
ASSETS: Check yes for each asset owned and enter the value. Enter who in the household owns the asset. TYPE OF ASSET VALUE ASSET OWNED BY
A. Home $
B. Real Estate (other than home) $
C. Investments: Stocks, Bonds, Retirement Account(s), $ Life Insurance, etc.
D. Vehicle(s) (i.e., car, truck, motorcycle) $ Additional vehicles $
E. Recreational Vehicle (s) (i.e., camper, ATV, $ snowmobile, boat)
F. Other $
8. EXPENSES
MAXIMUM
ALLOWED
ACTUAL COST FOR AMOUNT
MONTHLY EXPENSES AMOUNT (OFFICE
NEXT 30 DAYS (OFFICE USE
USE ONLY)
ONLY)
1. Food $ $ $ 0.00
2. Rent – Number of Bedrooms:
Name and Address of Landlord:
$ $ $ 0.00
3. Mortgage – Mortgage Holder: $ $ $ 0.00
4. Electricity –Hot Water Y/N Electric Heat Y/N $ $ $ 0.00
5. LP Gas $ $ $ 0.00
6. Heating Fuel TYPE: $ $ $ 0.00
7. Household/Personal Supplies $ $ $ 0.00
8. Prescriptions/Medical $ $ $ 0.00
9. Water $ $ $ 0.00
10. Sewer $ $ $ 0.00
11. Other essential needs (specify) $ $ $ 0.00
$ $ $ 0.00
TOTAL MONTHLY
HOUSEHOLD EXPENSES $ 0.00 $ 0.00 $ 0.00
9. OTHER EXPENSES
NOTE: The administrator should be aware of the following to gain an understanding of the applicant’s financial situation.
A. Do you have any debts (i.e., bank loans, car payments, credit cards)? YES NO
If YES, give (1) name; (2) purpose money was borrowed; and (3) amount (list below).
NAME PURPOSE AMOUNT
1. $
2. $
3. $
10. DEFICIT (Office use only)
A. Overall Maximum Level of D. Deficit
Assistance Allowed (If line A is greater than line B) 0.00
(See GA Ordinance Appendix A) $ $
B. Income E. *Surplus
(See Section 6) 0.00 (If line B is greater than line A) 0.00
$ $
C. Result * Note: If a surplus exists, applicant is not eligible for regular
(Line A minus line B) 0.00 GA. Proceed to Section 10 to determine if “unmet need”
$ results in eligibility for “emergency” GA
11. UNMET NEED (Office use only)
A. Allowed Expenses D. Unmet Need
(See Section 8) 0.00 (Amount from line C, but only if line A 0.00
$ is greater than line B) $
B. Income E. Deficit
(See Section 6) $ 0.00 (See Section 10, line D) $ 0.00
C. Result F. Amount of GA Eligibility
(Line A minus line B) $ 0.00 (The lower of line D and line E) $ 0.00INSTRUCTIONS:
1) If Section 10, line B (income) is greater than line A (overall maximum), then applicant has a surplus of $_____________ and will not be eligible for General Assistance unless the GA administrator determines there is need for emergency assistance.
2) If Section 11, line A (allowed expenses) is greater than line B (income), the result will be an “Unmet Need” (line D).
3) If there is both an “Unmet Need” (Section 11, line D) and a “Deficit” (Section 11, line E), the applicant will be eligible for the lower of the two amounts. This lower amount is the amount of assistance the applicant is eligible for in the next 30-day period, or a proportionate amount for a shorter period of eligibility (i.e., if the applicant needs one week’s worth of GA assistance, they should receive ¼ of the 30-day amount).
Administrator: Please read the following to the applicant or have the applicant read it in your presence.
In accordance with Maine law (22 M.R.S.A. § 4321) you have the right to be given a written decision concerning your application within 24 hours of submitting a completed application. If you disagree with the administrator’s decision on the application, you have the right to a fair hearing before an impartial hearing authority. If you believe that the municipality has violated state law with respect to your application, you have the right to notify the State Department of Health and Human Services in Augusta (1- 800-442-6003)
STATEMENT BY APPLICANT: I hereby affirm that the facts in this application are true, correct and complete, and that I have not knowingly withheld any information. I understand the Administrator has the right to verify any information necessary to determine my eligibility and hereby give my consent. I understand if I refuse to give my consent it may result in my not being eligible to receive assistance; therefore, I hereby give my express permission for the Administrator to contact the following specific sources or persons to verify any or all information material to the determination of General Assistance eligibility for my household:
• Employer(s) (past/present);
• Persons, organizations or businesses referenced in this application;
• Past, present and/or future landlords;
• Bank(s) or financial institutions;
• The Department of Health and Human Services or any department of the State of Maine;
• The area Community Action Program;
• Relatives, specify:_______________________________________ _________________________________________
• Persons/vendors to whom I owe money (i.e. utility company, fuel dealer, car dealership);
• Physician(s) with information related to my ability to work or receive other benefits;
• Housing Authority (local and/or state);
• The following specific sources of information_________________________ ________________________________
Applicant’s Signature:_______________________________________________________ Date:_________________________
Secondary Applicant’s Signature: ______________________________________________ Date: ________________________
Administrator’s Signature:____________________________________________________ Date:_________________________
Source: ga-app-fillable_03172025.pdf on durhammaine.gov. Text extracted with pdftotext; no wording has been corrected.