Combined Application for Benefits

This application contains information about the programs available at your local service center office, plus other very important information you should know, including your rights and responsibilities.

READ THIS APPLICATION CAREFULLY AND THOROUGHLY.

To complete the application, you may either:

• Download the application, fill it out on your computer, then print it, or
• Print the application and fill it out by hand.

After you complete, sign adn date your the application mail or take your application to an ESA service center.