ALPI Head Start/Early Head Start 2020-2021 Parent Survey

Emergency Assistance Is Available. Apply Online Now!

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The Agricultural and Labor Program, Inc.

POLK COUNTY UNITES FUNDS REQUEST

ALL ADULT HOUSEHOLD MEMBERS

Please complete the following information. Fields left blank could significantly slow the processing of this application.

HOUSEHOLD MONTHLY EXPENSES

(Signed W-9)
Be specific in your description.

DOCUMENTATION

The following documents must be provided. This is a critical part of the application process and any missing documentation could either slow down the processing or result in denial.

Click or drag files to this area to upload. You can upload up to 10 files.
Note: Allowable file formats include: pdf, jpg, png, tif, doc.

All the information I have provided above to the service provider is accurate, complete and current, to the best of my knowledge. I authorize the release of information related to determining my eligibility for assistance. I attest that I have not received any other COVID 19 funds or assistance from the CARES Act (exception - Stimulus check).

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