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Low-Income Assistance Application Form

Please complete the information below. Only 1 application per household.  Thank you!

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Favor de completar la forma. Solo 1 aplicación por familia. Gracias!

All information is confidential.
*Toda su información es confidencial.

- To Request FREE Services -

Please Complete The Following Steps

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- Para Recibir Servicios Gratuitos -

Favor De Seguir Los Pasos Siguientes

The below affidavit is required to be eligible for free benefits. The information will also assist us to know how much assistance will be provided.

***If you are homeless or have no income, please let us know

 

La declaración de ingresos mostrada abajo se requiere para recibir beneficios gratis. Esta información nos ayudará para saber cuánta provisión necesita.

***Si usted es vagabundo o no tiene ingresos, por favor avisanos

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email: Laradrakemodules@gmail.com

Self Affidavit of Income
Declaración de Ingresos

Annual Family Income/Ingresos Anuales & Persons per Household/Personas en casa
I am completing this form of my own free will/Completo esta forma por mi propia voluntad.

Thanks for submitting!

Lara Drake Modules Corporation  

A Nonprofit Charity - 170(b)(1)(A)(vi)

email: LaraDrakeModules@gmail.com

All funds raised through this website go directly to support our entire mission and will not be designated to a specific program.

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©2020 by Lara Drake Modules Corporation. All Rights Reserved

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