INSTRUCTIONS
The following questions are designed to determine your potential eligibility for benefits programs. You will receive the most complete benefits report if you answer all questions. Click the HELP link if you need help answering a question. Please do not click your browser's "Back" button while completing a screening, as your answers may not be saved.

1. Who are you completing this for? HELP
    
 
Please note:  If you are completing this for someone else, please answer all questions as if you are that person.
2. Are you male or female?
     Male  Female
3. What is the zip code for the area you would like to get help?