LIFT CAA is here to help!  We offer a wide range of community assistance programs.  If you or a family member need assistance, please fill in the form below.  After submitting the form, someone from our office will get back with you with more details on how we can help.

                

                        
Applicant Information
Type of Assistance*
ApartmentsCACFPCASADrug Free CommunitiesHappy Days ChildcareHead Start/Early Head StartHealthy StartHome Ownership CenterMarinaMentoring/PTTFSelf-Help HousingRSVPSHARETransit
Please choose one or more types of assistance that you are looking for.
Name*

                            
                            
                                                    First
                                                    
                                                
                            
                                                    Middle
                                                    
                                                
                            
                                                            Last
                                                            
                                                        
                            
                        
Date of Birth

                            
                            MM slash DD slash YYYY
                        
                        
Address*    
                    

                         
                                        Street Address
                                        
                                   
                                        Address Line 2
                                        
                                    
                                    City
                                    
                                 
                                        State
                                        AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
                                      
                                    ZIP Code
                                    
                                
                    

                
Phone*
Gender*

			

				
				Male
			
			

				
				Female
			
			

				
				
			
Race*

			

				
				White Non-Hispanic
			
			

				
				White Hispanic
			
			

				
				African American
			
			

				
				American Indian
			
			

				
				Asian
			
			

				
				Biracial/Multiple
			
			

				
				Native Hawaiian/Pacific Islander
			
			

				
				
			
Resident*
American CitizenDocumented AlienUndocumented Alien
Marital Status*
CohabitatingDivorcedMarriedSeparatedSingleWidowedYouth
Education*
0-8 grade9-12 gradeHS GraduateGED12+ Years2 Year Degree4 Year Degree4 Year Degree +
Health Insurance*
NoneDirect PurchaseEmployment BasedMedicaidMedicareMilitaryState AdultState ChildrenTribal
Military*
No MilitaryActiveVeteran
Food Stamps*

			

				
				Yes
			
			

				
				No
			
Disabled*

			

				
				Yes
			
			

				
				No
			
Work Status*
Employed Full TimeEmployed Part TimeNot in Labor ForceRetiredUnemployed < 6 mo.Unemployed > 6 mo.
Non-Cash Benefits

								
								WIC
							

								
								LIHEAP
							

								
								Section 8 Housing
							

								
								Public Housing
							

								
								Permanent Supportive Housing
							

								
								HUD-VASH
							

								
								Childcare Subsidy
							

								
								Affordable Care Act Subsidy
							

								
								Tribal Commodities
							

								
								Food Stamps
							
Disconnected Youth
In School/Not WorkingNot Working/In SchoolNot Working/Not In SchoolWorking/Not In School
Housing Type*
HomelessOther Permanent HousingOwn/BuyRent
Income

	

		

		

							

					Amount				
							

					Income Source				
						
Actions
		
		
		

		

							
 
							
 
						

				

					
Edit
										
Delete
				
			
		
		
		

		

			

				There are no Income and sources.			
		
		
	
	
				Add Income and source
				
			

				Maximum number of income and sources reached.
			

Energy Assistance: Do you need assistance with paying your gas or electric bill?

			

				
				Yes
			
			

				
				No
			
Are you related to anyone currently employed by LIFT CAA?

			

				
				Yes
			
			

				
				No
			
Answering yes to this question will not disqualify you from any program assistance.
Have you previously received services from LIFT CAA?

			

				
				Yes
			
			

				
				No
			
Answering yes to this question will not disqualify you from any program assistance.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.