Vaccine+ Assistance Intake Form

* - Required Field

Complete this form if you are a Connecticut resident interested in signing up for heating assistance, water assistance, and/or tax benefits for your kids. If you request heating or water assistance, you’ll get a call-back from your local Community Action Agency (CAA) in 2-3 days. If you request tax benefits for your kids, you’ll get outreach from SimplifyCT, a VITA tax provider that will help you sign up the Child Tax Credit and/or Earned Income Tax Credit.





Note: If possible, please share availability on weekdays from 9am-5pm. If not possible, enter the time(s) that work best for you.
Which of the following are you requesting? (select all that apply)*
Tax Benefits for my Kids
Heating Assistance
Water Assistance
Background information (selections will be collected anonymously).
 Yes  No *
 Yes  No *
Do you need help with any of the below? Select all that apply.*
Getting food
Learning about healthy eating
Learning about how to stay safe from COVID-19
Stress and anxiety
Loneliness
Housing
Financial assistance
Feeling safe at home
None
What is your race? Select all that apply.*
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
White
Prefer not to say
What is your ethnicity? Select one.*
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say