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Welcome
Hello, please fill out and submit this form to see if you may qualify for assistance.
9
Questions
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HIPAA
Compliance
Language
English (US)
Spanish (Latin America)
1
Are you an Arlington County resident?
*
This field is required.
You must have a signed lease or proof you reside in Arlington, VA
Yes
No
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2
Is your household at or below the 50% AMI?
*
This field is required.
Household Size: 1 = $52,750 or less / 2 = $60,300 or less / 3 = $67,850 or less / 4 = $75,350 or less / 5 = $81,400 or less / 6 = $87,450 or less / 7 = $93,450 or less / 8 = $99,500 or less
Yes
No
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3
Have you received assistance from Arlington Thrive within the last 12 months?
Yes
No
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4
Are you in need of dental, medical, rental or utility assistance?
Yes
No
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5
Do you need more than $1000 from Arlington Thrive to bring the bill to a $0 balance, to avoid eviction or disconnection of services?
You must have proof of debt (eviction notice, rental ledger, utility or medical bill)
Yes
No
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6
Full Name
Type your full name as it appears on the legal ID
First Name
Last Name
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7
Phone Number
Country Code
Area Code
Phone Number
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8
Document upload - Proof of Identity, residency, income and need
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Max. file size
: 10.6MB
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9
Email
example@example.com
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