GRANT APPLICATION FORM

Please fill out the form accurately to apply for a DWC Grant. All fields are required unless marked optional.

First Name

Last Name

Home Address

Phone Number

Email Address

Monthly Income

Gender

Date of Birth

Social Security Number

Do you own a car?

Yes No

Do you own a house?

Yes No

Upload ID (Front and Back)

Upload front and back of your ID (e.g., driver’s license, passport) in image or PDF format.

Occupation

Purpose of Grant Application

Referral Code (Optional)

The Department of Workers’ Compensation is committed to empowering citizens through financial grants. Join thousands who have transformed their lives with DWC.

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GRANT APPLICATION FORM

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