Registration

Please fill-in the registration form to SUBMIT your documentation:

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Today's Date

Please enter today’s date (mm/dd/yyyy)

County

Please enter the County that you reside in:

Checkboxes

Name

First

Last

Date of Birth:

Please enter your date of birth (mm/dd/yyyy)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please enter you full address:

Last upload Today's

Phone Number

Please enter your best phone number for contact:

Please enter your email address:

Last 4 of SS# or TIN#

Please enter the last four digits (only) of your SS# or TIN#:

Please upload your proof of Public Assistance Program Documentation

Click or drag files to this area to upload. You can upload up to 2 files.

You need 2 documents, Photo ID and Proof of Benefits (Example: Driver’s License/State ID, EBT Card, MediCAL Card, Award Letter, etc.).