Financial Assistance Application

Choose a language to download the application:

Need help?

For help completing the application, or to request free copies of our application form, please call a Customer Service Representative at 877-202-3597.

Sending in your completed application?

You can email, fax, or mail your completed applications to: 

PO Box 748632
Los Angeles, CA 90074-8632




In person:

Please contact Customer Service for the closest drop-off location at 877-202-3597.

Be sure to keep a copy for yourself.