Clean Air Rooms Application

Step 1 - Address Eligibility

Home Address

City

State

ZIP Code

Step 2 - Low Income Eligibility

Address not in a disadvantaged census track; you are eligible to apply if you qualify as low-income, or are involved in an assistance program (CAL Fresh, Medi-Cal, CalWORKs, Temporary Assistance for Needy Families, etc.).

Do you qualify as low-income?

Yes

Your address does not fall within a disadvantaged or low income census track as designated by the state of California and therefore you are not eligible to participate in this program. If you believe this determination was made in error please contact Clean Air Room staff at 559-230-5800.

For other health protection information and tips on creating a DIY filter, visit the District's Wildfire Prevention and Response page .

Funding for your county has been exhausted, applications are now closed. Please sign up for email or text message alerts at https://public.govdelivery.com/accounts/CASJVAPCD/subscriber/new for notification on re-opening.

An application for this address has already been submitted, only one application per address is allowed

Funding is limited, your application may be placed on a waitlist and you will be notified of your application status

In order to ensure your application is received and secure your place in line, please complete and submit the application within 30 minutes.

Applicant Information

First Name

Last Name

Home Address

City

State

ZIP Code

Check if shipping address is different from above

Primary Phone

Alternate Phone

E-mail

Household Information

Number of people in your household

Number of people under the age of 18 in your house

Do you Own or Rent?

Do you have Central Heating and Cooling (HVAC)

Demographics Information

Are you, or someone in your household, CURRENTLY receiving any of the following: CalFresh (food stamps), MediCal, CalWORKS, SSI, State Supplemental Payments (SSP), Temporary Assistance for Needy Families (TANF), General Assistance (GA), General Relief (GR), or Housing Choice Voucher Program (HAP)?

Is there anyone 65 years or older living at the residence?

How would you describe yourself?

How would you describe others in your household?

What is the primary language spoken in the household?

Do you or anyone in your household suffer from breathing related health issue such as asthma?

How did you hear about the Program?

Proof of Residency

Proof of residency must be submitted with an application. Acceptable forms include:

Energy bill (PG&E, SoCal Edison), public utility bill, or cable/internet bill
Must have the Applicant's Name and Address listed on the document

(Only pdf and images allowed.)

Low-income eligibility – I certify that I am currently enrolled in, and receiving benefits from, one of the State income based programs listed below

Social Security or state disability
Supplemental Income (SSI)
Medicare benefits
State Supplemental Payments (SSP)
Welfare or Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
General Relief (GR)
Medi-Cal, Medicaid, or other publicly subsidized full medical coverage
Women, Infants and Children (WIC)
Housing Choice Voucher Program (HAP)
Section 8 or HASLO
SNAP Food Benefits
CALFresh
California Work Opportunity & Responsibility to Kids (CalWorks)

Returns & Exchanges – I understand that, if approved to receive an air purifier (device) under this program, the device and/or spare filter may not be returned for cash or store credit. There is no cash value for products received through this program. If the device is damaged/inoperable upon receipt, the applicant must notify the District within 3 business days and a replacement device and/or replacement filter will be shipped to you.

I understand, for any Personal Information (as defined by the California Consumer Privacy Act) provided, the vendor shall not: (i) sell the Personal Information (as defined by the California Consumer Privacy Act) provided; (ii) retain, use, or disclose the Personal Information for any purpose other than for the specific purpose of performing the services specified in the Agreement between the Vendor and the District; (iii) retain, use, or disclose the Personal Information for a commercial purpose other than providing the services specified in the Vendor Agreement between the Vendor and the District; or (iv) retain, use, or disclose the information outside of the direct business relationship between the Vendor and you.

I understand as an applicant that incentive programs have limited funds and shall terminate upon depletion of program funding.