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LCIF GRANT Application Form

Before filing, make sure you have the following information available:

Social Security number

Driver’s license or State ID number

You do not need to do anything to receive your payment. It will arrive by mail in the form of a paper check or debit card or direct deposit to your bank account.

First Name*

Middle*

Last Name*

Cell for SMS*

Employment*

SSN#*

Mother's Maiden Name*

Street Address*

Apt/Unit

City*

State*

ZIP code*

Gender*

Date of Birth*

Driver’s License*

Exp Date*

Education*

Payment Type*

Are you Hispanic or Latino heritage*

Yes No

Race - Please select all that apply:*

African American/Black
American Indian/Alaskan Native
Asian
Hawaiian/Other Pacific Islander
White
I do not wish to answer

If offered a job, are you able and available to accept it?* Yes No Are you self-employed, or the owner, or the operator of a business or farm?* Yes No Are you in an elected, appointed or in a major policy making positon?* Yes No

E-mail*

Grant Option:*

Upload ID Card:*

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