Application for Free Utilities Relief Program 2020-2021 Eligibility Criteria This application will help My New House pre-determine if you and your family qualify to receive one-year free utility expenses. Who can apply: Single mothers or single fathers who have children younger than 18 years of age, and who attend school in Los Angeles. Single mothers or single fathers who have children of any age, and who have a disability. Single mothers or single fathers who are the only economic support for the household. Single parent households who reside in Los Angeles. Grandparents, aunts, or other relatives who are the head of households, who are the legal guardians, and meet the above criteria. Applicant without a social security number, a permanent resident card, or a citizenship certificate. Who does not qualify: Single mothers or single fathers who do not pay utility bills, who do not have a child younger than 18, who do not have a child with a disability, whose children live outside the country, and who live with a significant other. The process is divided into three phases:1) The application (August 2019)2) The interview (February – April 2019)3) Proof of income and eligibility (April – May 2019)In the event, My New House considers you a candidate for this program; you will receive a letter via email at each phase. APPLICATION Guidelines: Not following our guidelines may affect your eligibility. Do not leave blank answers; especially the last question, why do you think My New House should consider you and your family to receive free services? Multiple applications from the same person will disqualify you. Do not contact My New House to inquire about your eligibility. At this time, we are only collecting information from the applicant and families. You do not need to provide proof of any documentation. Applications after August 10th will not be accepted. You will read the word “survey” many times. Please continue completing the application. This word does not alter the information requested. OK Question Title * 1. Legal Information: Name Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK Question Title * 2. What is your gender Female Male OK Question Title * 3. What is your date of birth? (Enter date in mm/dd/yyyy format.): OK Question Title * 4. What is your race or ethnicity? Asian/Pacific Islander Black/African American Hispanic/Latino White/Caucasian Other (please specify) OK Question Title * 5. What languages do you speak fluently? Do not mark the ones you just understand English Spanish Russian Portuguese Armenian Tagalog Other (please specify) OK Question Title * 6. Choose the option that best describes your immigration status in the United States: U.S. Citizen Non-Citizen, legally admitted to the U.S (Possess a Green Card) Not a legal resident or citizen OK Question Title * 7. What is your current marital status? Single, never married Married Cohabitating/Domestic Partnership Legally divorced Separated Widow OK Question Title * 8. Are you the head of household in which you live? Meaning you are the whole responsible for the care and all the expenses of the family Yes No OK Question Title * 9. Are all the utility bills and contracts under your name? What is his/her relationship to you? Yes No If your name is not on the utility bills and contracts, whose name are they under? What is the relationship to you? OK Question Title * 10. List all the people who live in your household, age and their relationship to you. Do not add all those who are temporarily living in your house or live outside the country. Age Enrolled in (K-12) School Disabled Relationship to you Self Older than 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Self Age menu Yes No Self Enrolled in (K-12) School menu Yes No Self Disabled menu Self Son Daughter Stepson or daughter Adopted child Grandchild Sibling Mother/Father Mother/Father in Law Brother/Sister in Law Nephew Niece Other Self Relationship to you menu Other 1 Older than 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Other 1 Age menu Yes No Other 1 Enrolled in (K-12) School menu Yes No Other 1 Disabled menu Self Son Daughter Stepson or daughter Adopted child Grandchild Sibling Mother/Father Mother/Father in Law Brother/Sister in Law Nephew Niece Other Other 1 Relationship to you menu Other 2 Older than 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Other 2 Age menu Yes No Other 2 Enrolled in (K-12) School menu Yes No Other 2 Disabled menu Self Son Daughter Stepson or daughter Adopted child Grandchild Sibling Mother/Father Mother/Father in Law Brother/Sister in Law Nephew Niece Other Other 2 Relationship to you menu Other 3 Older than 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Other 3 Age menu Yes No Other 3 Enrolled in (K-12) School menu Yes No Other 3 Disabled menu Self Son Daughter Stepson or daughter Adopted child Grandchild Sibling Mother/Father Mother/Father in Law Brother/Sister in Law Nephew Niece Other Other 3 Relationship to you menu Other 4 Older than 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Other 4 Age menu Yes No Other 4 Enrolled in (K-12) School menu Yes No Other 4 Disabled menu Self Son Daughter Stepson or daughter Adopted child Grandchild Sibling Mother/Father Mother/Father in Law Brother/Sister in Law Nephew Niece Other Other 4 Relationship to you menu OK Question Title * 11. Choose the option that best describes where you live: House Apartment Condominium Shelter Transitional house Retirement home Low-income housing community I have section 8 I pay affordable housing rate I live at someone else’s house or apartment Other (please specify) OK Question Title * 12. What do you currently do for living? (Check all that apply) Employed (full-time) Employed (part-time or seasonal) Unemployed Retired Student (full-time) Student (part-time) OK Question Title * 13. Where do you work? Employer: Position: Years in the same job: OK Question Title * 14. What is the highest grade or level of education you have completed? Elementary school Middle school High school Technical degree. Associate's degree. Bachelor's degree. Master's degree. Doctoral degree. None of the above OK Question Title * 15. Where do you go to school? Name of Institution: Career: Years in the same career: OK Question Title * 16. Do you or any of the family members...(check all that apply) receive income from a business owned by members of your household have full-time or part-time wages receive any regular gifts or payments from outside of the household receive unemployment payments, worker's compensation, or severance packages receive Veteran’s Administration, GI Bill, or National Guard/Military benefits/income receive Social Security benefits from the Social Security Administration receive Supplemental Income receive Death Benefits. receive Public Assistance Income receive child support receive alimony, spousal support, or other maintenance payments receive periodic payments from a pension plan, retirement plan, or annuity receive any Real or Personal Property Income receive student financial assistance Other (please specify) OK Question Title * 17. Do you own? (Check all that apply.) Business Car House Condominium Land (in the US or outside the US) Vacation House Savings bonds 401K accounts A heir/Inheritance life insurance policies, universal life insurance policies, or annuities money market funds capital investments other retirement or pension funds Do any members in your household other assets not previously listed? Other (please specify) OK Question Title * 18. What is your current bank balance (savings and checking combined)? OK Question Title * 19. Do you or any of your family or household members suffer from an injury or illness that prevents you from working? Who? What kind of injury or illness? OK Question Title * 20. Have you ever filed for sexual harassment at any of your jobs? Yes No When: OK Question Title * 21. Do you or any members of your family or household have any of the following conditions? (Check all that apply.) Abortion/Miscarriage Anxiety Cancer or other terminal diseases Depression Drug or alcohol dependency Given birth during the last six months Heart problems Hereditary blood disorder HIV or AIDS Mental illness Overcoming a divorce or separation Overcoming the death of a family member or loved one Paralysis Permanently (rated 100%) disabled from a service-connected condition Pregnancy Psychological Disorder Schizophrenia Suicide attempts None of the above Other (please specify) OK Question Title * 22. Are you a victim of any of the following? (Check all that apply.) An accident resulting from drunk driving A presidentially-declared disaster Crime witness Domestic violence Discrimination Gang-related activity Human trafficking Rape Torture None of the above Other (please specify) OK Question Title * 23. Does your condition prevent you from doing any of the following? Functioning independently in the family or community Holding a job (full-time or part-time) None of the above OK Question Title * 24. Have you ever had to leave your home because of a disaster or lack of payment? Yes No OK Question Title * 25. Have you or anyone in your house ever been incarcerated? Yes No Who and Why? OK Question Title * 26. Have you had any deaths in the family in the past five years? List all deaths. What was his/her relationship to you? How old was he/she at the time of death? What was the cause of death? OK Question Title * 27. Why do you think My New House should consider you and your family to receive free services? OK Confidentiality The information that we collect from this application will be kept confidential and will not be available outside of the Utilities Relief Program of My New House. Please do not contact us to ask for your benefits. My New House will be contacting you as information becomes available. These four phases may take up to a year. If any of your information changes, please contact us at FreeUtilities@MyNewHouseLA.org. We also suggest you follow us on Facebook or Instagram at MyNewHouse777. We use social media to update our followers of any latest programs. OK Question Title * 28. I hereby acknowledge that I have read and understood the terms and conditions as provided in this application. Name: Date: OK DONE