CUSTOMER VALIDATION QUESTIONS

1. Which benefits are you currently receiving? Please note if you are not receiving any of these benefits, you do not qualify for the Adopt-A-Family program. The information entered will be verified.
(¿Qué beneficios está recibiendo actualmente? Tenga en cuenta que si no recibe ninguno de estos beneficios, no califica para el programa Adopt-A-Family. La información ingresada será verificada.) Value Required

2. At which DPSS office is your case located? Please note if you do not have a case open then you do not qualify for the Adopt-A-Family program. The information entered will be verified.
(¿En qué oficina del DPSS se encuentra su caso? Tenga en cuenta que si no tiene un caso abierto, entonces no califica para el programa Adopt-A-Family. La información ingresada será verificada.) Value Required

BASIC INFORMATION OF CUSTOMER

First Name
(Primer Nombre) Value Required

Last Name
(Apellido) Value Required

Date of Birth Value Required

Expected format: MM/DD/YYYY

Case Number
(Número de Caso) Value Required

CUSTOMER SIGNATURE

Current Address
(Direccion Actual) Value Required

City
(Ciudad) Value Required

State
(Estado) Value Required

CA

Zip Code
(Código Postal) Value Required

Mailing Address
(if different than above)
(Dirección de Envio) Value Required

City
(Ciudad) Value Required

State
(Estado) Value Required

CA

Zip Code
(Código Postal) Value Required

Telephone Number
(Número de Teléfono) Value Required

Alternate Telephone Number
(Número de Teléfono Alternativo) Value Required

Email
(Dirección de correo Electrónico) Value Required

CUSTOMER SIGNATURE

Preferred Language:
(Idioma Preferido) Value Required

Ethnicity:
(Etnia) Value Required

DESCRIPTIVE SUMMARY OF FAMILY/LIVING SITUATION

Text 1

CUSTOMER SIGNATURE

CUSTOMER SIGNATURE Collection

Text 1

CUSTOMER SIGNATURE

Radio 1