Transitional Assistance Application

General Information
Name*
First Name Middle Initial Last Name
Phone Number*
Email Address*
Name of Spouse*
First Name Middle Initial Last Name
Other Names or Spellings
Current Address*
Street Address Address Line 2 City State ZIP Code
Date Moved In*
Monthly Rent
Previous Address
Street Address Address Line 2 City State ZIP Code
I have lived in this township since:*
I have lived in this county since:*
I have lived in this state since:*
Date Of Birth*
MM
DD
YYYY
Birthplace*
City State
Social Security Number*
Please tell us why you need assistance.
Personal Information
Marital Status*
- Married
- Single
- Widowed
- Divorced
- Separated
- Deserted
Is there a court order for child support?*
- Yes
- No
Living Arrangement?*
- Rent
- Own
Landlord's Name and Address:
Past Employment
Name of Employer Address of Employer Type of Work Monthly Wage Start Date End Date Reason for Leaving
Present Income & Other Financial Information for Spouse if Applicable
Employment Salary/Commissions Person Receiving Employers Name and Address Weekly Amount
Public Assistance and Related Public Benefits
- Food Stamps
- TANF
- AABD
- General Assistance
Food Stamps
Person Receiving Amount
TANF
Person Receiving Amount
AABD
Person Receiving Amount
General Assistance
Person Receiving Amount
Cash Resources
Cash on Hand
Savings
Bank Accounts
Unemployment Benefits
Worker's Compensation
Veteran's Benefits
Annuities
Alimony/Child Support
Estates/Court Orders
Friends/Relatives
Government Bonds
Other Income
Do you have an Illinois Department of Human Services Medical Card, Medicaid, or any other insurance?*
Eligibility
Have you been denied a Cash Grant from IDHS?*
- Yes
- No
Have you had an IDHS case Termination because you have reached the lifetime limit?*
- Yes
- No
Have you ever been convicted in federal or state court of having made a fraudulent statement in order to receive assistance from any of the following: TANF, GA, or Social Security?*
- Yes
- No
Do you currently receive SSI or SSDI?*
- Yes
- No
Are you receiving or eligible for Unemployment Compensation Benefits?*
- Yes
- No
Do you have an active felony warrant for your arrest?*
- Yes
- No
Are you in violation of parole or probation in the State of Illinois?*
- Yes
- No
Do you have a State Class X or Class 1 Felony Drug conviction or Federal Law equivalent?*
- Yes
- No
Date of conviction
MM
DD
YYYY
County of conviction
Do you have children under the age of 18 in the household?*
- Yes
- No
Are you pregnant?*
- Yes
- No
If you answered YES to any of the above questions, then you are ineligible for General Assistance Transitional Assistance.
Please note which of the following you have applied for, been denied from, terminated from, or are currently receiving:
- SSI
- SSDI
- Food Stamps
SSI
Application Date Denied Date Termination Date Date Benefit Last Received Amount Received
SSDI
Application Date Denied Date Termination Date Date Benefit Last Received Amount Received
Food Stamps
Application Date Denied Date Termination Date Date Benefit Last Received Amount Received
Documentation
Required documentation includes:
- proof of residency
- proof of inability to work
- driver's license or state ID
- Social Security card
- birth certificate
- proof of SSI/SSD application
- poor of IDSH food stamp benefits
- proof of medical card
- proof of application for Affordable Health Care Act
- UI finding from IDES
- proof of charges from parole or probation officer
- other documentation as requested by township staff
Full details here: https://cctownship.com/wp-content/uploads/2020/07/GATA-List-of-Required-Documentation-May-2020.pdf
Upload all required documentation here.*
Drop files here or
Permission to apply on my behalf*
- I understand that if I want someone else to apply for General Assistance Transitional Assistance for me, and I am mentally and physically able to apply, I must provide a written statement that gives the person permission to apply on my behalf. The statement must include the full name, address and telephone number of the person applying for me. The statement must say that I am still responsible for the information that the person applying for me applying for me gives to the local General Assistance office. The statement must also say that I am liable for repaying benefits that were received due to incorrect or incomplete information provided by an approved representative.
Permission for someone else to sign*
- This application must be signed by the applicant; however, if the person is too ill, or otherwise mentally or physically unable to complete an application, this application may be filed by the spouse, parent, child, adult sibling, or other relative. If there are no relatives, this application may be signed by any other person able to furnish necessary information with reasonable competence.
Declaration of correct information*
- I have this application for General Assistance Transitional Assistance and declare under the penalties of perjury that to the best of my knowledge and belief, the information supplied in this application and all accompanying statements are true andd correct, and that it is a complete statement of all income, assets or resources belonging to me or to any member of my immediate family.
Information Authorization*
- I agree to notify the Supervisor of General Assistance Transitional Assistance of any change whatsoever in need, or in the resources listed herein, or any new or additional income or resources. Further, I hereby authorize any person, bank, firm, corporation, transfer agent, agency, institution or the Department of Human Services to furnish the Supervisor of General Assistance Transitional Assistance whatever information that may be requested relative to accounts, deposits, investments, securities, Railroad System Disability Income benefits, or business of any kind whatsoever.
Applicant's Signature*
Date*
Date Format: MM slash DD slash YYYY
Spouse's Signature
Date*
Date Format: MM slash DD slash YYYY
Applicant's Representative
- I hereby make an Application for General Assistance Transitional Assistance on behalf of the person named below and certify that, to the best of my knowledge and belief, the information furnished herein is a true statement of his/her income, assets and resources.
Applicant's Name
First Last
Applicant Representative's Signature
Relationship to Applicant
Name
This field is for validation purposes and should be left unchanged.

Name of Employer	Address of Employer	Type of Work	Monthly Wage	Start Date	End Date	Reason for Leaving

Employment Salary/Commissions	Person Receiving	Employers Name and Address	Weekly Amount

Application Date	Denied Date	Termination Date	Date Benefit Last Received	Amount Received

General Information

Personal Information

Cash Resources

Eligibility

If you answered YES to any of the above questions, then you are ineligible for General Assistance Transitional Assistance.

Documentation