418 2nd Ave W, Spencer, IA 51301
This application form must be fille dout correctly, and all relevant questions must be answered. All information on this application will be kept in strict confidence.
1) Families must be within 150% of poverty level income.
2017 150% Annual Poverty Level Income
For families/households with more than 8 persons, add $4,180 for each additional person.
2) Number of allowable vehicles (value shall not excees $18,000 per vehicle
3) Maximum Allowed in Checking/Savings/Investment Accounts:
4) Maximum amount of funding per reqeust is $750.
Please list below your approximate net out of pocket expenses for the year. This will be the cost you paid after Insurance, Title XIX, or any other supplement has paid.
I certify that the information provided on this applicatin is true and compelte to the best of my knowledge and I authorize the SPENCER CARES COMMITTEE to check for verification of this information as needed.
Legal Full Name (as you would sign):
Valid Email Address: