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Data Free Copy - Low Income Assistance

  1. Effective From 7/1/2019 to 6/30/2020 These are the income guidelines per number in household:
    Please add your initials to the income box that your household falls into.
  2. Example: 1. John Doe, DOB 1/15/1980, 40 yrs old
  3. Please Read and Select a response to the following statements
  4. (Examples Include: Wages/Salary, Child/Spousal Support, Cal WORKS, Social Security/Disability, Unemployment, Workers Compensation, Retirement Income, Rental Income, etc.)
  5. IMPORTANT: For verification purposes, please attach all forms of proof of income. If someone over the age of 18 does not have proof of income or is not a full-time student, you must submit verification from the unemployment office.
    Proof of income includes; recent pay stubs or a copy of the income tax return. You must show proof of all forms of income listed above.
  6. Please type First and Last Name
  7. Please type First and Last Name
  8. Please type First and Last Name
  9. For More Information Please Call (909) 370-5518 or Email
  10. Leave This Blank:

  11. This field is not part of the form submission.