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Prescreening Form

  1. 1. Which county do you live in?*

  2. 2. Select one of the following situations:*

  3. 3. Is your gross monthly income below the income guidelines outlined in the table below? Be sure to include all money received: EXAMPLE: income from work, net income for self-employment, lottery payments of $600 or more (other income that we will determine if it is excluded). NOTE: Guideline subject to change due to funding limitations.

  4. Family Size and Gross Monthly Income*

  5. Please be advised that completion of this information does not mean that you are already on the wait-list or the full eligibility application has been completed. You will be contacted by CCS regarding this prescreening that you have submitted.

  6. Leave This Blank:

  7. This field is not part of the form submission.