1

Please provide your contact information. Please note, eligible households must be St. Lucie County residents and meet the income requirements.

 *

Please provide your contact information. Please note, eligible households must be St. Lucie County residents and meet the income requirements.

First and Last Name: *	Address: *	City/Town: *
State: *(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	ZIP/Postal Code	Email:
Phone Number: *ext.

2

How did you hear about our program?

 *

How did you hear about our program?

Flyer	Facebook	Internet Search
Friend	211	Social Service Agency
Other: If other, type text here.

3

How many individuals are residing at the same address? Please include any children.

 *

How many individuals are residing at the same address? Please include any children.

4

Please select all forms of income currently being received by all individuals in the household.

 *

Please select all forms of income currently being received by all individuals in the household.

No Income	VA Pension	TANF
Social Security	VA Service Connection	Employment Wages
SSDI	VA Education Benefits	Unemployment
SSI	Child Support	Other: If other, type text here.

5

What is the household’s monthly gross income?

 *

What is the household’s monthly gross income?

6

Do you need your Florida’s photo ID or driver’s license?

 *

Do you need your Florida’s photo ID or driver’s license?

Photo ID

Driver's License

7

If seeking assistance with your driver's license, do you own any fees for reinstatement? 

If seeking assistance with your driver's license, do you own any fees for reinstatement?

Yes

No

8

Was your ID lost or stolen?

 *

Was your ID lost or stolen?

Yes

No

9

Do you have a current food stamp award letter?

 *

Do you have a current food stamp award letter?

Yes

No

10

Do you need your ID for:

 *

Do you need your ID for:

Work	Healthcare Services	School
Housing	Other: If other, type text here.

11

Do you have your original, state issued birth certificate? 

 *

Do you have your original, state issued birth certificate?

Yes

No

12

Do you need other documents such as a marriage license and/or divorce decree to obtain your ID/Driver’s License? 

 *

Do you need other documents such as a marriage license and/or divorce decree to obtain your ID/Driver’s License?

Yes

No

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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