Please answer each question and provide detailed responses. Completing this questionnaire does not guarantee receipt of any funding. By completing this form, you agree to provide financial and personal information that will be used by the committee to make their qualification decisions. You are also agreeing to an interview and/or a home visit by one or more LACCG board members, if you were selected as a possible candidate.
First Name (required)
Last Name (required)
Date of Birth (required)
Your Email (required)
Occupation/Employer
Home Address (required)
OwnRent
Best Contact Number (required)
Emergency Contact Number
How did you hear about this program?
Please name each member of your family living with you and provide their name, age, DOB, occupation/school and let us know their present health condition. Name - School/work - Age/Date of Birth - Health
If you have any other dependents that do not reside with you, please identify.
If you have kids in school, please describe how they are doing in school and if there have any learning disabilities or problems with the law.
Please in detail describe why you need financial assistance? (Please use a separate page if you need more space.)
Have you been ever convicted of a felony, accused of domestic violence, and/or arrested for any reason? If so explain:
Has your driver’s license been revoked or suspended: YesNo If yes, please explain:
Health conditions/medications
Primary care physician Name
Your PCP Phone Number
Has your spouse ever been convicted of a felony, accused of domestic violence and/or arrested for any reason? If so explain:
Has your driver’s license been revoked or suspended (Your Spouse): YesNo If yes, please explain:
Health conditions/medications (Your Spouse)
Primary care physician Name (Your Spouse)
Your PCP Phone Number (Your Spouse)
If you were selected, what temporary assistance are you and your family in need of? Please explain in detail and be as descriptive as possible.
Please let us know if you are receiving any State, Federal or other assistance and the source and amount of the assistance. (eg. State disability, food stamps…)
YOUR ELIGIBILITY FOR FINANCIAL AID CANNOT BE DETERMINED UNTIL THIS FORM IS COMPLETED, SIGNED, AND RETURNED TO LACCG.
WARNING: To receive funds from LACCG, all the financial aid, all information must be current and accurate to the best of your knowledge. If you purposely give false or misleading information, you may be subject to reimbursement of the funds. If the LACCG Committee suspects that any person may have engaged in a fraudulent submission of information in applying for this program funds, we will immediately terminate all funding and request full reimbursement. Fraudulent activities may include the use of false identities, forgery of signatures or certifications, and false claims of income, citizenship, or student status.
Full Name (required)
Date (required)
