Milpitas Assistance Program (MAP) Application

Milpitas Assistance Program (MAP) Application

If you have questions or need help completing your application, please call (408) 586-3405 or email MAP@ci.milpitas .ca.gov.

Applicant's Last Name

Applicant's First Name

Middle Initial

Language Preference*

The City of Milpitas recognizes we are a multilingual community. When possible, we will try to communicate in your preferred language. Please let us know your preference.

Spoken English/written English

Alternate Language

Select or enter value

Cell Phone

Home Phone

Full Address

Number of people living at this address

Are you the homeowner?

Is the City of Milpitas water bill is in your name?

Water Customer Number

Do you need childcare assistance for any children under age 12?

Is any minor listed here a foster youth or in the juvenile dependency system?

Household Income Qualifications

List the names of all adults and children in the household. Members who are not listed will not be eligible for MAP benefits. If you have more than five in your household, you will need to attach a sheet listing the additional members. Please fill out completely for every family member in your household. If you or a family member do not have income in a category, enter 0.

Applicant's Full Name*

Applicant's Birthdate*

Applicant's gross earnings from all jobs (pre-tax)*

Applicant's Pension, Retirement, Social Security*

Applicant's welfare benefit, child/spousal support*

Applicant's Other Income*

Person 2's Full Name

Person 2's Birthdate

Person 2's Gross earnings from all jobs (pre-tax)

Person 2's Pension, Retirement, Social Security

Person 2's welfare benefit, child/spousal support

Person 2's Other Income

Person 3's Full Name

Person 3's Birthdate

Person 3's Gross Earnings from all jobs (pre-tax)

Person 3's Pension, Retirement, Social Security

Person 3's welfare benefit, child/spousal support

Person 3's Other Income

Person 4's Full Name

Person 4's Birthdate

Person 4's Gross Earnings from all jobs (pre-tax)

Person 4's Pension, Retirement, Social Security

Person 4's Welfare Benefit, Child/Spousal Support

Person 4's Other Income

Person 5's Full Name

Person 5's Birthdate

Person 5's Gross Earnings from all jobs (pre-tax)

Person 5's Pension, Retirement, Social Security

Person 5's Welfare Benefit, Child/Spousal Support

Person 5's Other Income

Income Verification Documents*

Select

Documentation

Please upload PDF or JPEG images of the requested documentation. For your internet security, please black out account numbers and social security number. Do not attach any personal health information. For more info or help, call (408) 586-3405 or email map@ci.milpitas.ca.gov for more details.

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