*CONSUMER ELIGIBILITY To be eligible for Northern Nevada Center for Independent Living COVID-19 services, a person must have been affected by COVID-19 and/or the resulting economic shutdown. In order to document that you are eligible for these services, please answer the following: My income has been affected by COVID-19 Required field I was working until March 2020 and my hours have been cut I was working until March 2020 and I have been furloughed I was working until March 2020 and I have been laid off Services requested Required field Temporary Food Assistance Program Emergency Eviction Relief Program Personal Protective Equipment Other I can also use help with Required field Advocacy Independent Living Skills Peer Support Groups Social & Recreational Opportunities Technical Assistance Transition Services Housing Blind and Low Vision Life Skills Other Consumer Signature Required field Date Required field Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 CONSUMER INFORMATION Last Name Required field First Name Required field Address Required field City Required field State Required field ZIP Required field Telephone Number Required field County Required field Email Address Required field