General Assistance Pre-Screen Form

Please complete the following form to learn more about opportunities for General Assistance in Lucas County.

Please read our overview of the General Assistance program before submitting this pre-screen form. You'll find information on assistance that is and is not provided.

All fields are required to submit this form.

Pre-Screen Form

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:

Community Services

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