Adult Programs Financial Assistance Application

If you would like to be considered for financial assistance to cover the cost of CA’s Adult Program fees, please fill out the form below.  You will be asked to share personal financial information and to upload documentation (proof of income, expenses, assets) to assist us in determining need.

Currently, CA is unable to accept Medicaid or Medicaid-affiliated managed care plans for coverage of program fees.  Once the form is complete, someone from CA will get back to you within 10 business days regarding your inquiry.

 

 

Adult Programs: Application for Consideration of Financial Assistance

  • Please list names, ages, and relationships of all household members.
  • Please tell us how much you are able to contribute to the current residential fee.
  • Income (monthly from all sources) • Employment • Government Benefits • Income from Investments • Other (explain)
  • Expenses (monthly) • Housing (rent, mortgage, utilities) • Food • Car (payments, insurance, gas and maintenance) • Other (explain):
  • Assets • Home equity • Savings • Investments (all sources)
  • Please attach all documentation (income, expenses, assets) that you can provide to assist us in determining need: • Pay stubs • Most recent Federal Tax return • Documentation of monthly expenses
    Drop files here or
    Max. file size: 640 MB.
    • By providing my initials, I confirm the following: 1. By submitting this form, I am transmitting electronically the personal financial information of myself and/or of a person for whom I am the parent or guardian. 2. I also understand that by submitting this form, I am granting CA Human Services and its employees permission to review this personal financial information for the purposes of potential financial assistance to CA's Adult Programs. 3. I understand that someone from CA's staff will contact me within 10 business days following submission of this form with further information regarding financial assistance eligibility.
    • This field is for validation purposes and should be left unchanged.

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