COVID-19 Emergency Assistance Program Screening Application.
In order to be eligible for this program, you must:
• Apply as a family with children, meaning the household must consist of at least one adult and at least one child over whom an adult family member has legal custody.
• The family must reside in Los Angeles County.
• The household’s total annual gross income (before deducting taxes) must be 50% or less of the AMI.
• Have experienced a significant loss of income due to COVID-19.
• Households are eligible irrespective of immigration or documentation status.

If you meet these requirements and are interested in this emergency assistance program, please fill out this form, and a case manager will follow up with you in 7-10 days to continue your application process.

Once you are accepted into the program, your household can receive up to $3000 in financial assistance towards rent and/or utilities. In order to continue to receive the financial assistance, participant will be required to attend case management meetings.
Name *
Date *
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Phone Number *
Email Address *
How did you hear about our program? *
Do you have any children living with you? *
Number of Children *
Ages of Children *
Are there any other adults living with you in your home? *
If so, please list the names and relationship of the other adults living in your home (i.e., mom, spouse, sibling, etc.)
What city do you live in? *
What is your total monthly gross income? *
What is your total monthly rent? *
How much rent do you owe? *
Name of most recent employer: *
How was your work affected by COVID-19? *
If your hours were reduced, how many hours did your employer cut?
Have you applied for unemployment benefits? *
Have you received your stimulus check? *
Do you receive any government benefits? *
If you answered yes, which benefits do you currently receive?
Language interpretation needed? *
If you answered yes, what language:
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