Local Resident Eligibility Verification Form

Local Resident Eligibility Verification Form
Please complete all fields to verify your eligibility as a local resident. Do not include any sensitive identification or financial information.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Residential Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
How long have you lived at your current address?
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload Proof of Residency (e.g., utility bill, lease agreement)
Cancelof
Reason for Eligibility Verification
Are you currently residing at the address provided?
Should be Empty: