General Transitional Assistance Application - City of Champaign Township

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*

Birthplace*

City State

Social Security Number*

Please tell us why you need assistance.

Personal Information

Marital Status*

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

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

Statement of Support*

Please describe or explain how you have afforded to live thus far, prior to applying for the program.

Documentation

Documents will ultimately have to be brought in to the first meeting to be scanned in, but to ensure the applicant is eligible, documents must be uploaded on this application as well.

Proof of Residency within the limits of the City of Champaign, IL*

(Certification of Address or a Lease) MUST BE NOTARIZED