General Assistance (GA) Application

General Assistance (GA) Services I am applying for financial assistance for services for myself, as I am in need. I agree to supply information regarding resources and income and to notify LEKT GA Staff of any changes to my situation within ten (10) days of changes. LEKT GA is authorized to obtain information to establish eligibility. GA Services is intended to meet certain specified unmet needs of eligible individuals and/or families that are otherwise ineligible for TANF. The payments received are for costs directly related to shelter costs and basic living expenses, you must be living within the boundaries of the Lower Elwha Reservation and/or Service area.

Hidden

To be eligible for LEKT GA Services you must live within the LEKT Services Area. I am applying for financial assistance for services for myself, as I am in need. I agree to supply information regarding resources and income and to notify LEKT GA Staff of any changes to my situation within ten (10) days of changes. LEKT GA is authorized to obtain information to establish eligibility. GA Services is intended to meet certain specified unmet needs to eligible individuals and/or families that are otherwise ineligible for TANF. The payments received are for costs directly related to shelter cost and basic living expenses, you must be living within the boundaries of the Lower Elwha Reservation and/or Service area.

Date Submitted(Required)

Full Name of Applicant(Required)

First Middle Last Suffix

Housing(Required)

Own

Rent

Homeless

Physical Address(Required)

LEKT GA Applicants must live within the LEKT Services Area in Port Angeles, WA.

Street Address City WA ZIP Code

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number(Required)

Message Phone

Email Address(Required)

Gender(Required)

Female

Male

LGBTQ

Date of Birth(Required)

SSI Number(Required)

Marital Status(Required)

Applicant Tribe(Required)

Lower Elwha

Other

Enrollment Number(Required)

Disabled?(Required)

Yes

For Women, are you pregenant?(Required)

If Yes, apply for TANF Services

Yes

How many other people are in your Family Composition

List all additional household members that live with the applicant.

Household Member 1

Name(Required)

First Middle Last Suffix

Date of Birth(Required)

Relationship to HOH(Required)

Relationship(Required)

list relationship type

Hidden

Does this person receive income?(Required)

Earned or unearned income

Yes

Hidden

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child SUpport

Veterans Benefits

Other

Household Member 2

Name(Required)

First Middle Last Suffix

Date of Birth(Required)

Relationship to HOH(Required)

Household Member 3

Name(Required)

First Last Suffix

Date of Birth(Required)

Relationship to HOH(Required)

Hidden

Does this person receive income?(Required)

Earned or unearned income

Yes

Hidden

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child SUpport

Veterans Benefits

Other

Household Member 4

Name(Required)

First Last Suffix

Date of Birth(Required)

Relationship to HOH(Required)

Hidden

Does this person receive income?(Required)

Earned or unearned income

Yes

Hidden

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child SUpport

Veterans Benefits

Other

Household Member 5

Name(Required)

First Last Suffix

Date of Birth(Required)

Relationship to HOH(Required)

Hidden

Does this person receive income?(Required)

Earned or unearned income

Yes

HOUSEHOLD INCOME

Examples of earned and unearned income are: Wages for working, TANF, GA, Per Capita, child support, Retirement, SSI, casino winnings, inheritance, adoption support, foster care payments, rent/lease income, sale of timber, works compensation, alimony, gifts/prizes and/or veterans benefits.

Do you or your spouse have any form of earned or unearned income at this time?(Required)

If yes, complete Sections below for Earned & Unearned Income. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

Type of Income

Earned from wage form working

Unearned income

Both

At this time, I attest that I receive no form of earned and/or unearned income.

Applicant Initials(Required)

Significant Other Initials

Earned Income

Has anyone stopped working in the last 30 days?(Required)

Yes

Who stopped working?

First Last

Employer Name

Employer Phone number

Last Day of Work

Date of last Paycheck

Gross Income (Before Taxes)

Unearned Income

Examples of unearned income are: TANF, GA, Per Capita, child support, SSI, casino winnings, inheritance, adoption support, foster care payments, rent/lease income, sale of timber, works compensation, alimony, gifts/prizes and/or veterans benefits.

Do you and/or your spouse have any form of unearned income at this time?(Required)

If yes, complete additional information

Yes

Unearned Income Type(Required)

Examples: Per Capita, SSI Benefits, TANF, GA, Child Support, Veterans, etc.

Hidden

Unearned Income type(Required)

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Whose Income

First Last

Amount

Total amount received

Frequency Received

Weekly, monthly, bi-weekly

Date

HOUSEHOLD RESOURCES

A resource is anything that is own or is being bought that can be sold, traded, or converted into cash or money held by others. A resource does not include personal property such as furniture or clothing. Example of resources are: cash, checking/saving accounts, land, sales accounts, bonds, trusts, stocks, buildings, houses.

Do you and/or your spouse have any Resources to report(Required)

If yes, complete additional information

Yes

Type of Resource

Cash on hand, land, houses, trusts, bonds

Who owns the Resource

First Last

Location of Resource

Value of Resource

approximate value

Do own a vehicle?(Required)

Yes

Primary Vehicle(Required)

Please list the primary vehicle that is used to transport the children in the family unit. If you do not have a vehicle, please leave blank.

Year Make (Toyota) Model (Tacoma)

EDUCATION INFORMATION

Have you received your High School Diploma?(Required)

Yes

What was the last grade you completed?

High School Name

Have you received your GED?(Required)

Yes

School name where you received your GED

Are you a FULL time student?(Required)

Yes

Type of School

High School

College

Current School Name

Employment background (Types of jobs you have held in the past)

EDUCATIONAL OR EMPLOYMENT GOALS

Please describe your short and long term goals for education/employment so we can write these into your individual responsibility plan, should you be found eligible for the program.

MEDICAL EXMPETION STATEMENT

Please describe what your medical condition is; how this makes you unable to work and the date of the onset or length of time you have been considered medical exempt. Please have your medical provider / physicians complete the medical provider/physician report or provide documentation. If documentation is not provided, you will be required to participate in work like activities until received. If medical exemption is longer than 90 days, please understand you will be required to apply for SSI benefits.

Upload any additional required documents here

Tribal Enrollment Verification Picture ID (all adults) Income Verification Landlord Statement

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Certification

I read or had explained and understand the information in this application. I declare under perjury, the information I provided in this application is true, correct, and complete to the best of my knowledge. I understand that if I incorrectly receive a grant from the LEKT GA Program because I have made a willful false statement or because I have willfully failed to report information required by the Program, any and all services will be terminated, forwarded to the LEKT Prosecutor and full repayment will be sought prior to being eligible for future services

Signature(Required)

Landlord Statement

This is a required document to determine GA Eligibility. Please complete the following information. If you are applying as homeless

The following information can be transferred from my application to my housing landlord statement.

Head of Household Name & all contact information

Housing Situation

All the People listed on this application

Main Heating Source is

Electric

Wood

Propane

Signature