First Name:

 *

First Name:

Last Name:

 *

Last Name:

Address:

 *

Address:

City, State, Zip Code: 

 *

City, State, Zip Code:

Phone Number:

 *

Phone Number:ext.

Email:

Email:

1. How did you hear about the Cooling Fan Assistance Program?

(i.e. Social Media, TV, City Website, etc.)

2. Are you 60 years or older?

 *

2. Are you 60 years or older?

Yes

No

Applicants must be 60 years of age or older to be eligible.  Please attach a copy of your government issued photo I.D. to verify age and identity.

Applicants must be 60 years of age or older to be eligible. Please attach a copy of your government issued photo I.D. to verify age and identity. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

3. Do you currently have an air conditioning unit in your home?  

 *

3. Do you currently have an air conditioning unit in your home?

Yes (specify what type - i.e. Central Air, Fan, Wall Unit, etc.) If other, type text here.

No

4. What type of housing unit do you live in? 

 *

(i.e. House, apartment, shared room, board/care, facility, other)

5. Do you live in low-income subsidized housing? 

5. Do you live in low-income subsidized housing?

Yes (specify what type - Ex: Senior housing, Section 8, low-income unit, etc.) If other, type text here.

No

6. What is your total gross annual income?Please complete the boxes below.

 *

6. What is your total gross annual income?Please complete the boxes below.

My total family* size consists of

members including myself, and the total gross annual income** for all adult members is

 
*”Family” is defined as: All persons  living in a household who are related by birth, marriage or  adoption.

**Gross annual income must include all sources of income (wages, child support, SSI, unemployment, pension, income from assets, etc., but does not include the income of live-in aids, per 24 CFR 5.403).

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Eligibility Income Limits

 

Income Verification - Please select one or more of the items below you will provide for proof of income:

 *

Income Verification - Please select one or more of the items below you will provide for proof of income:

Employment, Pay Stubs,W-2 (Box 1 Gross Income)

Self-employment, Business Income, 1099

Disability Income

TANF/CalWORKs/General Relief/Public Assistance Income

Unemployment Income

Worker’s Compensation

Child Support

Social Security, Pension, Retirement

Other: Specify If other, type text here.

Proof of income is required to verify eligibility. Please attach a copy of all of the items selected above as proof of income. You will need to compile all documents into one file to upload below.

Proof of income is required to verify eligibility. Please attach a copy of all of the items selected above as proof of income. You will need to compile all documents into one file to upload below. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

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7. Do you have a medical condition that gets worse with heat?

 *

7. Do you have a medical condition that gets worse with heat?

Yes

No

8. Are you affected by COVID-19 either by exposure, or at high risk to exposure due to age or compromised immune system?

 *

8. Are you affected by COVID-19 either by exposure, or at high risk to exposure due to age or compromised immune system?

Yes

No

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WARNING:

 *

I certify that the information contained on this form is complete and true to the best of my knowledge. I authorize the City of Glendale or its providers/agencies to request and obtain income documentation from me, if necessary. WARNING: Section n1001 of Title 18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. Making false statements is a felony under California State Law (Penal Code Sections: 115, 118, 487, 532) and may result in criminal charges.

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Please review your answers for accuracy. 

When ready, please click the green 'SUBMIT' button below

 Please call (818) 548-2187 for additional questions or assistance.

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

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