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General Assistance Screening Form

  1. Include children, relatives, and roommates.

  2. Marital Status:

  3. Reason for Request:

  4. Yes or No

  5. 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.)

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

  7. Do you have/own:

  8. United States Citizenship Attestation

  9. For the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, I attest as follows:

  10. Attestation

    I hereby attest that my response and the information provided on this form and any related application for public benefits are true, complete, and accurate and I understand that this information may be used to verify my lawful presence in the United States.

  11. This is for screening purposes only. Our office will contact you by phone, mail, or email for further information.

  12. 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.

  13. Leave This Blank:

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