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General Assistance Online Screening Form

  1. Income before taxes.

  2. Are you receiving any type of Social Security?*
  3. Are you applying for SSI?*
  4. Are you a Veteran?*
  5. Are you a Student?*
  6. Please provide a dollar amount.

  7. Please provide a dollar amount.

  8. Leave This Blank:

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