Verification of Eligibility for Local Public Benefit Required by Ind. Code 12-32-1

  • I state under penalty of perjury that the statements checked above are true to the best of my knowledge.
  • Please enter your name as your electronic signature.

Application for Township Assistance is to be completed by each person who applies for township assistance. The trustee has the power to administer oaths. Any person expressing a desire for assistance shall be permitted to apply, whether or not the trustee believes the person to be eligible.

Each completed form must be filed in the trustee’s office, whether or not relief is granted on the application. The trustee shall not extend aid to persons or families unless an affidavit setting forth the personal condition of the family has been filed within one hundred eighty (180) days prior to the date of the extension of aid.

An individual filing an application and affidavit on behalf of a household must provide the names of all household members and any information necessary for determining for household’s eligibility for township assistance

This form allows you to begin the process of checking eligibility, but will not prevent the person requesting aid from having to eventually come into the Trustee’s Office to finalize the eligibility process.

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