The below verifications may be necessary to determine eligibility. Please submit the following information with your application.

Verifications

• Picture ID
• Proof of Jefferson County residency
• Birth Certificate, DD214, Passport, Naturalization Papers, or Permanent Legal Resident Card
• Social Security Number
• All checking and savings accounts, showing current balance
• Current month of earned or unearned income verification (including any Social Security income, pensions, annuities, retirement income, or paystubs)
• Verification of any real estate property or land
• Copies of all vehicle registrations, including mileage

Copy of the provider’s proposed charges

• To be provided at time of application showing request for payment (burial services, rent, transportation, utilities, prescriptions, etc.)

Failure to provide the above verifications may delay processing of benefits or result in the denial of your application for burial assistance.

General Assistance may be granted to eligible individuals when County funds are available to support this program. Reimbursement to individuals for services rendered is not permitted.
Benefits must be paid directly to a provider.

Questions? Please call our team at 303-271-1388

*If you are applying on behalf of another individual as their authorized representative or for burial assistance on behalf of the deceased individual, include their information in this section. A decedent must have been a resident of Jefferson County at their time of death to be eligible to apply for General Assistance.

Complete this section only if you are applying on behalf of anther individual as their authorized representative or for burial assistance of the deceased individual.

Please list information regarding everyone in the home of the person listed in the General Information section.

Please fill out the following for any income coming into your home. This includes employment income, unemployment benefits, child support, Retirement/Pension, Social Security benefits, SSI, SSDI, Veterans Benefits, Veteran Widow, Dividends/Interest, Alimony, Worker's Compensation, Disability Benefits, Financial Aid, Railroad Retirement, Rental Income, Survivor Benefits, Other Cash Received Monthly.

If Employed, please complete the following:

If Employed, please complete the following:

If Employed, please complete the following:

If Employed, please complete the following:

I state that i have examined this application, and to the best of my knowledge, believe my answers are true, including household composition and citizenship information, and I have listed all amounts and soureces of income I receive.