This form is used to determine whether or not you may qualify to receive a free desktop PC bundle which includes the Desktop, Monitor, Keyboard and Mouse, as well as all necessary cables. Please Carefully Fill Out the FollowingFirst and Last Name *Phone Number *E-mail We will contact you in regards to your eligibilityAre you currently receiving some form of Federal Assistance? *YesNoWho is filling out this form? *ParentGuardian/FosterCase WorkerStudentWhat is your estimated annual household income? *How many children are in the household? *Do you or your child have any disabilities? *PhysicalMentalNoneDo you currently receive housing aid? *YesNoAre you a victim of domestic abuse? This field is optionalYesNoHow many schools has your student attended in the past 4 years? How did you hear about us? *211 LA/OCSchoolFriend/FamilyCase WorkerBrowsing the InternetOther VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: