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City of Spencer

treardon@spenceriowacity.com

418 2nd Ave W, Spencer, IA 51301

(712) 580-7200

Form Section 1

SPENCER CARES APPLICATION

This application form must be filled out correctly, and all relevant questions must be answered.  All information on this application will be kept in strict confidence. 

QUALIFICATION GUIDELINES

1) Families must be within 150% of poverty level income.

2017 150% Annual Poverty Level Income

1 2 3 4 5 6 7 8
$18,210 $24,690 $31,170 $37,650 $44,130 $50,610 $57,090 63,570

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

Family Size Number of Allowed Vehicles
1 members No more than 1 vehicle
2 members No more than 2 vehicles
3 members No more than 2 vehicles, unless 3 members working
4-7 members No more than 2 vehicles, unless 3 members working

 

3) Maximum Allowed in Checking/Savings/Investment Accounts:

1 2 3 4 5 6 7
$5,000 $5,500 $6,000 $6,500 $7,000 $7,500 $8,000

 

4) Maximum amount of funding per request is $750.

Form Section 2
APPLICANT INFORMATION *
Form Section 3

APPLICANT INFORMATION

Do you own your home? *
Is your home paid for?
Are you delinquent in making your payments?
Do you rent your home or apartment?
Are you delinquent in making your payments?
Form Section 4
Do you have excessive medical expense? *

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. 

Form Section 5
Have you applied for assistance elsewhere? *
Form Section 6

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.