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The form must be completed by the person providing help or sharing expenses, requiring specific dollar amounts for loans or direct support over the last two months and plans for ongoing assistance. It asks whether the helper allows the person to stay, how household expenses are divided, whether bills have been paid (with types and amounts), and whether the person has employment or other income. 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Give specific answers to  \nthe following questions about the money you have loaned or given directly to this person. When  \ncompleting this form please do not use phrases such as “amount varies”, “it varies from month to month”, or “as much as I can”. We need specific dollar amounts to determine eligibility. This form should be completed by the person providing help and/or sharing expenses with the client.  \nName of Client:   Client’s address:   Name of person providing help (Person completing this form):   Your address:   Contact Phone:   Your relationship to the client listed above:  Are you allowing this person to stay with you and are you paying all household expenses? Yes   No   Do you share expenses?   Yes   No. If yes, how are expenses divided?  \nClient’s share of: Rent $  Utilities $  Other $   List how much money you have given this person(s) in the last 2 months. If no cash provided, please list $0.00 for the Amount Given.  \n| Month and Year | Amount Given | Reason Help Provided (ex. Rent, Food, Shelter, other) |\n| --- | --- | --- |\n|  | S |  |\n|  | $ |  |\n\nDo you plan to continue to help this person(s)? Yes  No    \nIf yes, how much per month? $   \nIs this help a gift or a loan? (A loan is if you expect the person to repay you)   Have you paid any bills for this person? Yes  No   \nIf yes, List the type of expenses and amounts paid for client (Please only include the client’s share of the expense) :  \n\n| Type of Bill (Electric, Water, Car Insurance, etc   ) | Amount Paid |\n| --- | --- |\n|  |  |\n|  |  |\n\nIs this person working or have any other sources of income? Yes   No    \nIf yes, where are they employed and/or what other type of income:    \nSignature of person providing help Date  \nIn accordance with Federal law, the Department of Health is prohibited from discriminating on the basis of race, color, national origin, sex, age,  \ndisability, religion, political belief or marital status.  \n04/08/2015","cbCaitj4D2Y5f7m4","https://ap.wps.com/l/cbCaitj4D2Y5f7m4","pdf",49493,"English","# Letter of Support\n## Client and helper details\n## Household expenses and shared costs\n## Past support amounts and reasons\n## Ongoing help and monthly amount\n## Gift or loan; bills paid\n## Employment and other income\n## Signature and date","[{\"question\":\"Who should complete this Letter of Support?\",\"answer\":\"The person providing help and/or sharing expenses with the client should complete the form.\"},{\"question\":\"What information is required about money given to the client?\",\"answer\":\"Provide specific dollar amounts for the last 2 months, including the month and year, how much was given, and the reason (such as rent, food, or shelter).\"},{\"question\":\"How does the form determine eligibility for ongoing assistance?\",\"answer\":\"It asks whether the helper plans to continue providing help, the amount per month if yes, and whether the help is a gift or a loan (expecting repayment).\"},{\"question\":\"What questions are asked about bills and income?\",\"answer\":\"The form asks whether any bills have been paid for the client (type and amount for the client’s share only) and whether the person is working or has other sources of income, including where they are employed or the type of income.\"}]","Letter of Support - Assistance Eligibility Form | PDF",1789563486]