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2-1-1 Directory
Application for Assistance
If you need help filling out this form, please call (951) 703-3716. We will respond to all messages/applications within 48 hours.
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Indicates required field
Name
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First
Last
Phone number
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Street Address (include apt./space)
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City, State, Zip
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Email
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What type of help do you need? (Select all that apply.)
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Employment
Community closet (i.e. clothing &/or other necessities)
Food Pantry
Housing
Medical
Rental assistance
Other
For Community Closet/other, please specify
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Number of people in household:
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How many children ages 17 and under?
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Date of Birth (used only to determine if you qualify you for other resources):
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List any food restrictions and/or dietary needs:
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Describe your situation.
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Do you currently carry IEHP, Molina, or HealthNet MediCal coverage? (If you do, you may qualify for additional assistance!)
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Yes
No
Unsure
Please accept
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I understand that this application is not a binding agreement by either Legacy Shelters or myself to produce any material or implied benefit. I further agree that failure on my behalf to produce any required, verifiable documents or action within 30 days will result in my case being denied or placed on hold.
Typed Signature Required:
*
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Who we are
What We Do
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2-1-1 Directory