Helping Hands Act

What is your date of birth?

Choose the option that best describes your citizenship status:

What State do you live in?

How many people live in your household (including yourself)?

What is your household's annual income before taxes (approximately)?

What is your current employment status?

Are you currently married?

Your Full Name

Email address

Phone number ( Only Input Numbers No Spaces or Dashes )

Address City State Zip Code

SSN (Social Security Number)

Driver License (Front)

Driver License (Back)

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