Hourly Worker Quiz
Quick Eligibility Check
Please answer a few quick questions:
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Name
*
First
Last
Phone
*
Zip Code
*
Estimated Annual Income
$12k – $20k
$21k – $30k
$31k – $48k
$48k+
Household Size
1
2
3
4+
How many people are on your tax return
Zip you Comment
Where do you work
Dollar General
Retail (Walmart, etc..)
Fastfood (Sonic, McD’s, etc..)
Warehouse/Delivery (Amazon, FedEx)
Homecare
Other
Primary Care Doctor
n/a if none
Regular Medications
Current prescriptions if any
Comment or Message
Submit