Question title

* Proof of residency

Please attach a copy of your driver's license or utility bill.

Question title

* Household Composition

For each person in your household, list their name, age, relationship to the Head of Household, and whether they are enrolled in CHAMPS.

Question title

* Are you Hispanic?

Poll question: Are you Hispanic?. Select one option.
Use Tab to navigate between options, Space or Enter to select
Select a response

Question title

* What is your race? (Select all that apply.)

Poll question: What is your race? (Select all that apply.). Select one or more options.
Use Tab to navigate between options, Space or Enter to select
Select a response

Question title

* By typing my full name, I certify to the best of my knowledge and belief that the provided herein is true, complete and accurate. I am aware that the provisions of false, fictious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative consequences including, but not limited to violations of U.S. Code Title 18, Section 2, 1001, 1343 and Title 31, Sections 3729-3730 and 3801-3812.