Phone: 805-736-3423 | Fax: 805-735-7672
815 West Ocean Avenue, Lompoc, CA 93436
Please fill out the form below if you have experienced a loss or change in income. A staff member will reach out to you as soon as possible. Please include as much detail as possible.
* = required fields.
Please submit online or print the completed form with supporting documentation and drop off at any of our drop box locations listed below:
Amount Frequency *
The reported change will be effective on the first day of the next month.
I certify under penalty of perjury that the reported change(s) are true and correct and any additional changes will be reported immediately.
HACSB USE ONLY