I need help (our programs are at capacity, filling out this form puts you on the wait list)

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Are you in need of supplies or support?

If you are within a 30 minute drive from Playa del Rey (zip code 90293) or have URGENT needs use this form. If not please sign up at www.mutualaidla.org

Please tell us your name *

Please tell us what you need (please be as specific as possible e.g. groceries, household goods, baby supplies) *

Please tell us your phone number *

Please tell us your email address *

Please tell us your address or cross streets *

Please tell us the best time to deliver to you!

Mon

Tue

Wed

Thu

Fri

Sat

Sun

1pm - 3pm

Please tell us your or household income *

$0 to $20,000

$20,001 - $40,000

$40,001 - $60,000

$60,001 - $80,000

$80,001 - $100,000

$100,001 or more

Prefer not to say

What are you current sources of income? *

Examples: General Relief, Social Security, ...

Please tell us your year of birth *

Please tell us how many people are living off the income *

For example, if you put "F 43, M 45, O 18" in previous question then put 3

Please tell us about your housing *

Living on street or vehicle

Living in shelter or other subsidized housing

Renting - at risk of losing housing

Renting - NOT at risk of losing housing

Home owner - at risk of losing housing

Home owner - NOT at risk of losing housing

Is there anything else you want to tell us?

Would you like to volunteer?

If so go to GrassRootsNeighbors.org and sign up

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