GENERAL RELIEF (GR) APPLICATION - Los Angeles County

LOS ANGELES COUNTY

DEPARTMENT OF PUBLIC SOCIAL SERVICES

GENERAL RELIEF (GR) APPLICATION

PURPOSE OF THIS FORM: By filling out this form, you will apply for General Relief (GR) from the Department of Public Social Services (DPSS).

Do you need a translator? There is no fee for this service.

Yes No

Do you need help applying because of a disability?

Yes No

If you answered `Yes', after you complete and submit this form, a DPSS worker will contact you.

All information I will give on this application will be true and correct. I know that giving false information, hiding or not giving facts on this application is fraud.

I am making this application for General Relief on my, or the applicant's behalf:

_____________________________________________________________________________________________

Applicant's Signature

Date

_____________________________________________________________________________________________

Spouse/Domestic Partner/Representative's Signature

Date

1. Today's Date: ____/____/_____

MM DD YYYY

2. Case Number: _____________________________________

LEAVE BLANK IF YOU DO NOT HAVE ONE

3. Name: ____________________________________________________________________________________

LAST NAME

FIRST NAME

4. Date of Birth: _____/____/______ 5. Social Security Number: ____________________ 6. Gender M F

MM DD YYYY

7. What DPSS Office do you want your GR case to be sent to? Circle 1 location.

Civic Center 813 E. Fourth Place Los Angeles, CA 90013

Metro Special 2707 S. Grand Ave. Los Angeles, CA 90007

San Gabriel Valley 3352 Aerojet Ave. El Monte, CA 91731

Rancho Park 11110 W. Pico Blvd. Los Angeles, CA 90064

Glendale

Pasadena

4680 San Fernando Rd. 955 N. Lake Ave.

Glendale, CA 91204

Pasadena, CA 91104

South Central 10728 S. Central Ave. Los Angeles, CA 90059

Wilshire 2415 W. 6th St. Los Angeles, CA 90057

Lancaster General Relief Sub Office 337 East Ave K-10 Lancaster, CA 93535

Pomona 2040 W. Holt Ave. Pomona, CA 91768

South Special 17600 B Santa Fe Ave. East Rancho Dominguez, CA 90221

Metro East 2855 E. Olympic Blvd. Los Angeles, CA 90023

San Fernando Sub Office Southwest Special

9188 Glenoaks Blvd.

1819 Charlie Sifford Dr.

Sun Valley, CA 91352

Los Angeles, CA 90047

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LOS ANGELES COUNTY

DEPARTMENT OF PUBLIC SOCIAL SERVICES

8. Are you homeless? Yes

No

8a. Do you want to use the DPSS Office as

your mailing address?

Yes No, I have a mailing address:

________________________________________

STREET ADDRESS

________________________________________

APARTMENT/SUITE/OTHER

________________________________________

CITY

STATE

ZIP CODE

8b. Home Address:

________________________________________

STREET ADDRESS

________________________________________

APARTMENT/SUITE/OTHER

________________________________________

CITY

STATE

ZIP CODE

8c. Do you pay rent?

No

Yes

Amount: $______________

9. What language(s) do you speak?

English Spanish Other ________________

10. What language(s) do you read?

English Spanish Other ________________

11. Cell No: __(________)_________________________ 12. Home No: __(________)______________________

13. E-Mail Address: ________________________________________________________________________________

14. Status: Single Married Domestic Partner

15. Is anyone else applying with you? Note: Married spouses and domestic partners must apply together.

No

Yes

15a. Who is applying with you?

____________________________________________________________

LAST NAME

FIRST NAME

15b. Their Date of Birth _____/_____/_______

15c. Their Gender M F

15d. Their Social Security Number: _______________________________

15e. Your spouse/domestic partner must fill out the GENERAL RELIEF APPLICATION SUPPLEMENTAL form

16. Are you a Veteran of the U.S. Armed Forces?

Yes No

17. Are you a U.S Citizen?

Yes

No

(Go to #18 on the next page)

17a. Do you have an alien number?

Yes: _______________________________________ No

ALIEN NUMBER

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LOS ANGELES COUNTY

DEPARTMENT OF PUBLIC SOCIAL SERVICES

18. Have you been in Los Angeles County for at least 15 days?

19. Do you plan to stay in Los Angeles County?

20. Are you on parole or probation right now?

21. Are you fleeing to avoid prosecution or custody/confinement after a felony conviction?

22. Do you have any income?

Yes

No (Go to #23)

Yes No Yes No Yes No Yes No

22a. Where is the income coming from?

A job. Unemployment Benefits. Disability Benefits.

Veteran's Benefits. Pension. Other: __________________________

22b. How much income do you get and how often? $ ________________

Daily.

Weekly.

Every other week.

Twice a month. Monthly.

Other:_________________________________

HOW OFTEN?

23. Check all Assets that you own: A car(s). Check even if it does not run. Cash-on-hand/amount*: $ _________ Savings account.** Other: _______________________

A home/trailer/mobile home/other property. Checking account.** Insurance policy.

* Put in the amount that is available today. ** Check even if you have a $0 balance in the account.

24. Check any items that prevent you from working or taking part in an employment program?

Physical health condition. Mental health condition. Other:____________________

25. An Authorized Representative is someone who can make decisions for you and talk to the Department of Public Social Services about your case. Do you want an Authorized Representative on your case?

Yes

No (you are done)

25a. Name of your Authorized Representative:

_____________________________________________________________________________________

LAST NAME

FIRST NAME

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LOS ANGELES COUNTY

DEPARTMENT OF PUBLIC SOCIAL SERVICES

GENERAL RELIEF APPLICATION SUPPLEMENTAL ? SPOUSE/DOMESTIC PARTNER ONLY All spouses and domestic partners must apply for GR together. This form must be completed by your spouse or domestic partner and submitted with the GR Application.

First/Last Name: ___________________________ Case Number: _______________________

Please answer the following questions about yourself:

1. Do you have a disability and need help applying?

Yes No

2. Are you a Veteran of the U.S. Armed Forces?

Yes No

3. Are you a U.S. born Citizen or Naturalized Citizen?

Yes No

If no, what is your alien number (if applicable)? ________________________

4. Have you been in Los Angeles County for at least

Yes No

15 days?

5. Do you plan to stay in Los Angeles County?

Yes No

6. Are you currently on parole/probation?

Yes No

7. Are you fleeing to avoid prosecution or Custody or

Yes No

confinement after a felony conviction?

Income & Property

8. Do you receive income? Yes No

Where is the income coming from?

A job Unemployment Benefits

Disability Benefits Veteran's Benefits Pension Other _____________

How much income is received and how often? $ ________________

Daily Weekly Every other week Twice a month Monthly Other

9. Do you own property or assets? Yes No

Examples of property include: land, houses, apartments, cars (including mobile homes or trailers, etc., Examples of assets include: cash, bank accounts, insurance policies, etc.,)

What property do you own? A car(s) A home/trailer/mobile home/other property Check all

that apply:

Cash-on-hand/amount: $ _________

Savings account Checking account

Insurance policy

Other _______________________

Employability Please answer the following questions for yourself:

10. Do you have any of the below that prevents you from working or participating in an employment program?

Physical health condition Mental health condition Other

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