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Applicant Information

STEP 1

Applicant Information

Contact Information

Email
Phone
Text Message

Address

Login Information

Please create a password. Make sure it meets all of the following criteria:
Must be at least 8 characters
Must contain upper and lower case characters
Must contain at least one number
Must contain at least one special character
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Verify Email and Phone

STEP 2

Verify Email and Phone

Verify Email Address

Please verify your email below. Use the 5-digit code we have sent to

Household Benefits Programs

STEP 4

Household Benefits Program

Please tell us if your household receives benefits from any of the following federal or state assistance program.
Click all that apply.

You must choose at least one program and upload the corresponding document, or choose that you do not receive any benefits.

SSI (Supplemental Security Income)

Do you receive this benefit?

Yes
No

SNAP (Supplemental Nutrition Assistance Program)

Do you receive this benefit?

Yes
No

TANF (Temporary Assistance for Needy Families)

Do you receive this benefit?

Yes
No

Other

Do you receive other benefits?

Yes
No

Household Members

STEP 5

Household Members

List all household members, starting with Applicant, Social Security numbers are required for applicant and all household members. For applicants or members of an applicant's household who do not have a Social Security Number, you should enter "99-99-9999" in the Social Security Number field.

What types of income are included in an application for a rebate?

Household income includes earnings for all residents over the age of 18, including full or part-time work from a traditional job (W-2), self-employment (1099), owning a business, retirement income (SSI and pension), disability income (SDI), and investment income.

Household Member #1

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Add Household Member

Total Household Income

$0

Benefits Agreement

STEP 7

Benefits Agreement

Applicant Signature

Disclaimer

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