Paper Applications

Print Paper Application Aplicacion en Español

It should include all household members (even if living with friends and family). Income verification is required for all household members over 18. Income should be verified through the following methods:

• Last 30 days of earned income

• Last 30 days of bank statement

• Benefit letters (SSDI / SSI)

• W2(‘s) or previous tax return

• DWS Employer Verification Form (Form ESD 630) 

• Self-Declaration of Income (for self-employment or no income) (not the preferred method and to be used only after all other avenues have been exhausted – may also slow down application).

Once the application is complete, please call 435-674-5757 and leave a message on the general assistance voicemail. You can also email your application to amerrill@fivecounty.utah.gov. A staff person will follow-up and schedule an appointment.

Please allow 3 business days for a response.