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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: *
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