18 years of age or older

Authorized to work in the US?

Registered for selective service (males born after 1959 only; males born during or before 1959 and females, please select "N/A"); check registration at https://www.sss.gov?

Do you meet any one of the following:

• Temporarily or permanently laid off due to COVID.
• Unemployed six out of the past 13 weeks.
• Dependent spouse of a military member on active duty whose income was reduced due to: deployment, permanent change of station, or service-connected death or disability of that person.
• Receiving or have exhausted unemployment benefits and are unable to find job in your last occupation.
• Laid off but not eligible for unemployment benefits and are unable to find a job in your last occupation.
• Received a notice of termination from your current employer due to company closure.
• Self-employed and now unemployed due to economic conditions or a natural disaster.
• No longer able to depend on the income of a family member.
• Receive cash (TANF) or food assistance (SNAP).
• Receive Social Security or Veterans’ Administration disability rated benefits.
• In a household that meets low-income criteria based on Poverty Guidelines.

  Family Household Size	Maximum Income
  1	$28,278
  2	$46,334
  3	$47,696
  4	$58,884
  5	$69,498
  6	$81,281
  7	$93,063
  8	$104,846

• Are Basic Skills Deficient. (Unable to speak, read, write, compute or solve problems in English to function on the job, within the family, or in society.) Yes No