Keeping it Cool Form Click Here for a Printable Form First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Primary Phone(Required)Secondary PhoneEmail (optional) Home Address(Required)Mailing Address (if different from Home Address)Gender(Required) Female Male Other Prefer not to say Race (check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Prefer not to say Ethnicity(Required) Not Hispanic or Latino Hispanic or Latino Prefer not to say What assistance are you in need of? {check all that apply)(Required) Window A/C Unit Table Fan No preference Do you currently use an air conditioner? Yes No What type of unit is it? Window Portable Central If you are found eligible to receive a Window A/C Unit, will you have someone available to assist you with pick up and installation? Yes No Were you referred to us by another agency? Yes No Please provide the name of the agency below. What is your household's primary language?(Required) English Portuguese Spanish Haitian-Creole Cape Verdean-Creole French Chinese Other What is your source of income? (check all that apply)(Required) Employed Full Time (30+ hours) Employed Part Time (less than 30 hours) Retired SSI/Disability Unemployed Other Other Language Explain other income # of people in household ages 60+(Required) 0 1 2 3 4+ # of people in household ages 19-59(Required) 0 1 2 3 4+ # of people in household ages 0-18(Required) 0 1 2 3 4+ Are you a veteran? Yes No Are you currently receiving SNAP (food stamp) benefits? No Yes Do you live in subsidized housing? Yes No Do you receive fuel assistance? Yes No Do you or a family member have a medical condition that makes it uncomfortable to be in extreme heat, such as COPD, Asthma, etc? Yes No 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 Is your total household income at or below the amount listed on the chart above? Yes No Do you have other needs that we can help you with? Please explain below. Today's Date(Required) MM slash DD slash YYYY Applicant Signature(Required)