LACCG Questionnaire For Financial Assistance

    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.

    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.

    Has your driver’s license been revoked or suspended:

    If yes, please explain:

    Has your driver’s license been revoked or suspended (Your Spouse):

    If yes, please explain:

    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.