Solicitud de asistencia financiera para programas para adultos

Si desea que se le considere para recibir asistencia financiera para cubrir el costo de las tarifas del Programa de Adultos de CA, complete el formulario a continuación. Se le pedirá que comparta información financiera personal y que cargue documentación (comprobante de ingresos, gastos, activos) para ayudarnos a determinar la necesidad.

Actualmente, CA no puede aceptar Medicaid o planes de atención administrada afiliados a Medicaid para la cobertura de las tarifas del programa. Una vez que se complete el formulario, alguien de CA se comunicará con usted dentro de los 10 días hábiles con respecto a su consulta.

Adult Programs: Application for Consideration of Financial Assistance

Name of family member filing out the application*
On behalf of (potential resident):*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Names of all household members*
Please list names, ages, and relationships of all household members.
Please summarize why support is necessary*
How much are you able to contribute to the current residential fee?*
Please tell us how much you are able to contribute to the current residential fee.
Monthly Income (from all sources)*
Income (monthly from all sources) • Employment • Government Benefits • Income from Investments • Other (explain)
Total Monthly Income:*
Monthly Expenses*
Expenses (monthly) • Housing (rent, mortgage, utilities) • Food • Car (payments, insurance, gas and maintenance) • Other (explain):
Total Monthly Expenses*
Assets*
Assets • Home equity • Savings • Investments (all sources)
Total assets*
Please attach all documentation that you can provide to assist us in determining need:*
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: 256 MB.
Disclosure (Please Initial)*
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.
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Solicitud de asistencia financiera para programas para adultos

Adult Programs: Application for Consideration of Financial Assistance

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