Atascosa Inter-Agency Council

Request Assistance

This application is for screening purposes only and does not guarantee your eligibility to receive services. This application will be provided to the AIC committee for review and a decision will then be made as to the merit of the request.
Please complete all questions truthfully.

Personal Information

Full Name *required

Please provide your full name.

Drivers' Lic. # *required

Please provide your drivers licsense number.

Social Security # *required

Please provide your social secruity number.

Email *required

Please provide a valid email.

Home/Mobile Phone # *required

Please provide a valid home or mobile number.

Work Phone #

Street Address *required

Please provide a valid home street address.

City *required

Please provide a valid city.

Mailing Address (If different)

Marital Status *required

Household Information

Name of Person

Age

Sex

Disabled

Veteran

Assistance/Income Information

Child Support Amount *required

Food Stamps Amount *required

TANF Amount *required

SSI Amount *required

Rent or Own Home *required

Rent/Mortgage Amount *required

Public Housing? *required

Housing Amount *required

Utilities Included in Rent? *required

Employment/Education Information

Employment Status *required

Reliable Transportation? *required

Reliable Childcare? *required

Do you have a diploma or GED? *required

Do you have college hours or technical trade? *required

Additional Information

Assistance Details *required

Agency Requests *required

Services Recieved from AIC *required

Comments

Suggestions / Comments

Upload Documentation

Required documentation:

Copy of an ID for of all family members in household.
Copy of the bill you need help with or the lease if it is rent.
Copy of your income for the last month. (Check stub, letter or estimate if no check stubs or unable to acquire a letter.)
Proof of income from everyone in the household. (This includes wages, family help, SSI, Medicare, etc.)

Application will not be considered if any requested documentation is not provided.

Attach Required Documents *required

Hold Ctrl and select multiple files

I confirm that all required documentation has been provided.

The statements above are true and the assistance that you are requesting represents your situation truthfully.

I understand that this application and information will be presented to the committee and I, ______________ authorize and give permission for the release of this information to the Atascosa Inter-Agency Council (AIC) and any other agency for verification of the statements and for determination purposes.

I further understand I am subject to prosecution for providing false or fraudulent information and can be denied additional assistance.