If you would prefer to print the paper application please find the PDF application here. Otherwise, please fill out the following fields.

    

Today's date
Summarize your reason for this request and what your goals are:
If you are unemployed, how long have you been without a job? Did you quit or were you terminated?
Have you filed a Veterans Affairs Federal Compensation or Pension claim? If so, explain:
Contact information
Dependent's name and date of birth
Dependent Name Date of Birth
Has your household applied for Temporary Emergency Assistance before through this office?
Has your household applied for General Assistance through Johnson County before?
Is anyone in your household a student taking classes past high school?
Type of assistance you are seeking?
Rent Water Electric/Gas Groceries Other
How many people are in your household (including yourself)?
Does anyone in your household receive any other type of assistance?
Food Assistance Social Security Housing/Section 8/SSVF/HUDVASH Unemployment Other
Please list the last 4 weeks of household income:
Income listing for the last 4 weeks
Household Income $ Amount
Gross Wages/Salary
VA Compensation/Pension
Social Security/SSI/SS/SSDI
Unemployment
Food Assistance
Private Earnings (Cash)
Hud Housing (Section 8)
Child Support
Other Income
Have you supplied the following:
DD-214 or discharge papers of eligible Veteran showing character of discharge
One file only.
35 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Last 4 weeks of bank statements and pay stubs for all members of the household
One file only.
35 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Current lease in Veteran or Spouse's name signed by landlord and applicant (if applying for rent)
One file only.
35 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Utility invoice in Veteran or Spouse's name (if applying for utility assistance)
One file only.
35 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

I (we) authorize communication or release of confidential information by Johnson County, or its duly appointed representatives, to any individuals, institutions, businesses, and/or agencies necessary for determining eligibility for assistance, billing reimbursement purposes.

I (we) understand that I (we) have the right to inspect the disclosed information at any time. I (we) understand that this consent will remain in force until termination of assistance from Johnson County Commission of Veterans Affairs.

I (we) consent to and authorize any local, state, or government agency, private business, firm, agency, bank, trust company, postal savings department, insurance company, financial institution, or other applicable agencies to share information.

I (we) understand that I (we) may revoke the CONSENT TO RELEASE AND EXCHANGE INFORMATION at any time. I (we) do hereby and forever release and discharge all of the individuals, institutions, businesses, agencies, and JOHNSON COUNTY IOWA, its agents and employees, from any liability for releasing information whether such information is deemed confidential or not. A photocopy of this form shall be considered the same as the original.

I agree to Consent to Release or Exchange Information
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