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General Assistance Re-Certification Form

  1. Yes or No

  2. Yes or No

  3. Yes or No

  4. Have you received any money or benefits from the following? If so, please state when and how much. (Please also indicate if you have recently applied for any of the benefits listed.)

  5. Did family or friends pay on any of the following? If so, please state when and how much.

  6. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  7. Leave This Blank:

  8. This field is not part of the form submission.