Device Request Form

Please complete this form to request a device. Fields marked with * are required.

Event/Org

Date

Contact Information

Name

Phone *

Email *

1. Ethnic Identification

African AmericanAsianLatino(a)Native AmericanWhite (Non-LatinX)OtherDecline to State

2. Primary Language Spoken at Home

EnglishSpanishChinese

Other (please specify)

3. Household Annual Income

$19,999 and under$20,000 – $39,999$40,000 – $59,999$60,000 – $99,000$100,000 or MoreDecline to State

4. Need for Device

No device in householdCurrent device(s) in household outdatedEducational needs — school aged children and/or individual(s) pursuing higher level education or vocation trainingEmployment — ability to identify, apply, and obtain employment and/or work remotelySocial service needs — ability to access County and other on-line governmental services and/or subsidiesTelehealth or other personal services — medical consultations, on-line therapy, wellness activities, financial & legal servicesOther

Other (please specify)

5. Residential Address

Street Number and Name

City

Zip Code

6. Federal, State or County Benefits You Currently Receive

Name of Federal benefits

Name of Federal benefits:

Name of State benefits

Name of State benefits:

Name of County benefits

Name of County benefits:

I receive assistance from local Food Banks.I receive assistance to pay my bills.Other

Other (please specify)

7. Agreement to Participate in Follow Up Survey

I agree to participate in follow-up surveys sponsored by the County of Los Angeles. I may be contacted at the above mailing address, telephone number, and email address. (Please select one of the choices below).

Yes

Date

First Name

Last Name