Online Application Please enable JavaScript in your browser to complete this form.Application Check ListDD214 Member 4Copy of Valid ID to prove Cameron County ResidencyLast 3 Check stubs from applicant and spouse if applicableif unemployed please provide unemployment letterProof of late rent/utilitiesEviction Notice if applicableVerifiable SourcesProof of IncomeMarriage License if applicableDate *Type of Assistance *UtilitiesRentEducationMedicalEmploymentEmail *Applicant RelationshipVeteranSurviving SpouseName *FirstLastPermanent AddressCity, State, Zip codeDate of Birth *AgeBranch of ServiceType of DischargePhone NumberAlternative Phone NumberGenderFemaleMaleMarital StatusSingleMarriedDivorcedSeparatedWidowEthnicityOtherAfrican AmericanAnglo AmericanAsian AmericanCaucasianEuropean AmericanHispanicNative AmericanMexican AmericanMiddle Eastern AmericanPacific IslanderService Start DateService Release DateDropdownActiveReservesNational GuardDischargedDisabled VeteranYesNoHousehold IncomeDisability Rating (percent) Selected Value: 1 Employment StatusEmployableUnemployableAre you enrolled at a VA Clininc?YesNoLocationCampaign InformationOIFOEFKoreaGulfVietnamOtherNot ApplicableSign and Date using this box. (By typing your name you are signing this form) *I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for assistance consideration and may be grounds for termination of any future assistance. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, human resources staff, and other authorized employees of Cameron County. This consent shall continue to be effective during my assistance. I understand that applications submitted for assistance are public records. I certify that to the best of my knowledge and belief all the statements contained herein and on any attachments are true, correct, complete, and made in good faith.MessageSubmit
