Keeping it Cool Form - City of Brockton

First Name(Required)

Last Name(Required)

Primary Phone(Required)

Secondary Phone

Email (optional)

Home Address(Required)

Mailing Address (if different from Home Address)

Please provide the name of the agency below.

Other Language

Explain other income

Please explain the medical condition

Family Size (# of people In the household)	100% Federal Poverty Level*	200% Federal Poverty Level*
1	$12,760	$25,520
2	$17,240	$34,480
3	$21,720	$43,440
4	$26,200	$52,400
5	$30,680	$61,360
6	$35,160	$70,320
7	$39,640	$79,280
8	$44,120	$88,240

Do you have other needs that we can help you with? Please explain below.

Today's Date(Required)

Applicant Signature(Required)