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SITE INFORMATION

THIS INFORMATION IS RELEASED TO THE PUBLIC


FOR REFERRAL AND PRESS RELEASES.
hra A homeowners and renters
assistance volunteer program
for the disabled and elderly.

SEE SIDE 2 FOR CODES 첸 CHECK HERE IF YOU DO NOT WANT THIS
INFORMATION RELEASED TO THE PUBLIC.
DATE______/_______/______

SPONSOR NUMBER SITE NUMBER MAJOR SPONSOR CODE COUNTY CODE DISTRICT CODE

NAME OF LOCATION

STREET ADDRESS

CITY ZIP CODE

E-MAIL ADDRESS __________________________________________


PUBLIC CONTACT PERSON PUBLIC TELEPHONE NUMBER (OPTIONAL)
NAME (AREA CODE) TELEPHONE NUMBER

OTHER LANGUAGE ASSISTANCE (List type, i.e., Spanish)


DAY AND TIME Begin (circle) End (circle)
am am
Monday
: pm : pm
am am
Tuesday
: pm : pm
am am
Wednesday
: pm : pm
am am
Thursday
: pm : pm
am am
Friday
: pm : pm
am am
Saturday SERVICES
: pm : pm
am am Check boxes that apply
Sunday
: pm : pm
첸 BY APPOINTMENT ONLY 첸 NO PUBLIC ASSISTANCE
am am
Lunch
: pm : pm 첸 SHUT-IN ASSISTANCE 첸 WALK-INS & APPOINTMENTS

첸 DISABLED ACCESS

OPENING DATE ______/_______/______

CLOSING DATE ______/_______/______

FTB 4595HRA ( REV 05-2002) SIDE 1 03-20000 SIDE 1 California Volunteers Make the Dif ference
Major Sponsor Codes
Code Sponsor Code Sponsor
01 AARP 13 Military
02 Assembly Office 14 Other
03 City 15 Project Scout
04 College/University 16 Red Cross
05 Community Center 17 Religious Organization
06 Congressional Office 18 R.S.V.P.
07 Corporate 19 Salvation Army
08 Department of Aging - Area Agency on Aging 20 Senior Citizen Center
09 Golden Umbrella 21 Senior Information and Referral Center
10 High School 22 Senior Escort
11 I.R.S. 23 Social Security Office
12 Library 24 State Senate Office
25 United Way

County Codes Field Office Codes


Code County Code District
01 Alameda 21 Marin 41 San Mateo 23 Bakersfield
02 Alpine 22 Mariposa 42 Santa Barbara 73 Fresno
03 Amador 23 Mendocino 43 Santa Clara 25 Long Beach
04 Butte 24 Merced 44 Santa Cruz 21 Los Angeles
05 Calaveras 25 Modoc 45 Shasta 75 Oakland
06 Colusa 26 Mono 46 Sierra 11 Sacramento
07 Contra Costa 27 Monterey 47 Siskiyou 29 San Bernardino
08 Del Norte 28 Napa 48 Solano 31 San Diego
09 El Dorado 29 Nevada 49 Sonoma 71 San Francisco
10 Fresno 30 Orange 50 Stanislaus 77 San Jose
11 Glenn 31 Placer 51 Sutter 33 Santa Ana
12 Humboldt 32 Plumas 52 Tehama 79 Santa Rosa
13 Imperial 33 Riverside 53 Trinity 81 Stockton
14 Inyo 34 Sacramento 54 Tulare 39 Van Nuys
15 Kern 35 San Benito 55 Tuolumne 35 Ventura
16 Kings 36 San Bernardino 56 Ventura 27 West Covina
17 Lake 37 San Diego 57 Yolo
18 Lassen 38 San Francisco 58 Yuba
19 Los Angeles 39 San Joaquin
20 Madera 40 San Luis Obispo

FTB 4595HRA (REV 05-2002) SIDE 2 03-20000 SIDE 1