Guaranteed Income for Trans People (GIFT)
Program Application
Lyon-Martin Community Health Services & The Transgender District, in partnership with the
Mayor’s Office of Trans Initiatives, the San Francisco Treasury, and the Mayor’s Office of Housing
& Community Development is proud to present the first Guaranteed Income Program specifically
for Transgender people. GIFT is a financial assistance program for low-income Transgender, Non-
Binary, Gender Non-Conforming, and Intersex (TGI) people who reside in the City and County of
San Francisco, CA. This program is currently only available for those 18 years of age and older.
If enrolled, the City and County of San Francisco will provide $1,200.00 per month to those who
maintain eligibility for the program for 18 months. Eligibility is determined based on multiple
factors including city of residence, income, priority population, and availability of funds. You may
use the funds to pay for anything. The only additional requirement to stay enrolled in the
program is the completion of a survey every 3 months.
We can assist you with the application if you schedule an appointment with one of our Economic
Empowerment Coordinators (in person, by phone, or by virtual visit) by calling (415) 213-1717,
emailing GIFT@lyon-martin.org, or by dropping into our clinic at 1735 Mission Street in San
Francisco during our hours of operation.
Or you may apply on your own without assistance by submitting the following documents to us
online through our website www.GIFTincome.org or via email at GIFT@lyon-martin.org
This application form
A copy of your photo ID (if you have one)
A copy of proof of residence in the City & County of San Francisco
A copy of documents that verify your income
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Please answer the following questions to the best of your ability:
General Information
Name Legal Name (on ID, if different)
Date of Birth Phone Number
Email Address Mailing Address
Social Security Number (if you have one) Preferred Language
Emergency Contact Name Emergency Contact Phone Number or Email
What is your preferred method of communication?
Phone
Email
Letter
Case Manager/Friend/Family member:_______________________________________
Insurance or Coverage Plan Name Insurance or Coverage Plan ID Number
Income
Gross Income per Month (before taxes Number of People in Household
& expenses)
Check all income sources that apply to Employment
you Cash Economy Work
Unemployment
Supplemental Security Income (SSI)
Social State Disability Insurance (SSDI)
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CalWORKS
County Adult Assistance Program (CAAP)
Cash Assistance Linked to Medi-Cal (CALM)
Cash Assistance Program for Immigrants (CAPI)
Refugee Cash Assistance
Student Financial Aid
Not Listed: _________________________
Check any non-cash assistance Medi-Cal
programs you are currently enrolled in Medicare
Healthy San Francisco
CalFresh (Food Stamps)
Not Listed: _________________________
Please include proof of income such as:
W2
Bank Statement(s)
Pay Stubs
Unemployment Award Letter
SSI Award Letter
SSDI Award Letter
CalWORKS Award Letter
CAAP/CALM/CAPI Award Letter
Financial Aid Award Letter
Self-Attestation Letter
Please include proof of residence such as:
Lease
Mail
Utility Bill (internet, phone, or PGE, etc)
Homeless verification letter (from an agency such as shelter, drop in center, social
services organization, or healthcare provider)
What district/neighborhood of San Francisco do you live in? ____________________________
3
Demographics
Trans Status (Check all that Transgender
apply) Non-Binary
Gender Non-Conforming
Intersex
None of the above
Pronouns (Check all that She/her/hers
apply) He/him/his
They/them/theirs
It/its/its
Co/co/cos
Zie/zim/zis
Ze/hir/hirs
Xe/xem/xyrs
Ey/em/eirs
E/em/eirs
Per/per/pers
Fae/faer/faers
Ae/aer/aers
Tey/ter/ters
Ve/ver/vis
No pronouns/just name
Declined
Not Listed: _____________________________
Gender Identity (Check all Cis-gender woman
that apply) Woman
Transgender Woman
Woman of Trans experience
Woman with a history of gender transition
Trans feminine
Feminine-of-center
MTF (male-to-female)
Demigirl
T-girl
Transgirl
Sistergirl
Cis-gender man
Man
Transgender man
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Man of Trans experience
Man with a history of gender transition
Trans masculine
Masculine-of-center
FTM (female-to-male)
Demiboy
T-boy
Transguy
Brotherboy
Trans
Transgender
Transsexual
Non-binary
Genderqueer
Agender
Xenogender
Fem
Femme
Butch
Boi
Stud
Aggressive (AG)
Androgyne
Tomboy
Gender outlaw
Gender non-conforming
Gender variant
Gender fluid
Genderfuck
Bi-gender
Multi-gender
Pangender
Gender creative
Gender expansive
Third gender
Neutrois
Omnigender
Polygender
Graygender
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Intergender
Maverique
Novigender
Two-spirit
Hijra
Kathoey
Muxe
Khanith/Xanith
X-gender
MTX
FTX
Bakla
Mahu
Fa’afafine
Waria
Palao’ana
Ashtime
Mashoga
Mangaiko
Chibados
Tida wena
Bixa’ah
Alyha
Hwame
Lhamana
Nadleehi
Dilbaa
Winkte
Ninauposkitzipxpe
Machi-embra
Quariwarmi
Chuckchi
Whakawahine
Fakaleiti
Calabai
Calalai
Bissu
Acault
Travesti
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Questioning
I don’t use labels
Declined
Not Listed: _____________________________
Sex Assigned at Birth Female
Male
Intersex
Unknown
Not Recorded
Declined
Sexual Orientation (Check Aromantic
all that apply) Asexual
BDSM/Kink
Bisexual
Demisexual
Dyke
Faggot
Gay
Lesbian
Non-monogamous
Pansexual
Polyamorous
Queer
Same-Gender Loving
Skoliosexual
Heterosexual (Straight)
T4T (Trans 4 Trans)
Don’t Know
Not Listed: _____________________________
Are you Yes
Latine/Latinx/Hispanic? No
Decline
Which best describes your Indigenous
Race? (Check all that apply) o American Indian/Native American (Specific Group:
__________________)
o Indigenous from Mexico, the Caribbean, Central
America, or South America (Specific Group:
__________________)
o Other Indigenous: __________________
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Asian
o Chinese
o Filipinx
o Japanese
o Korean
o Mongolian
o Central Asian
o South Asian
o Southeast Asian
o Other Asian: __________________
Latine
o Caribbean
o Central American
o Mexican
o South American
o Other Latine: __________________
Black
o African
o African American
o Caribbean, Central American, South American or
Mexican
o Other Black: __________________
Middle Eastern/West Asian or North African
o North African
o West Asian
o Other Middle Eastern or North African
Pacific Islander
o Chamorro
o Native Hawaiian
o Samoan
o Other Pacific Islander: __________________
White
o European
o Other White: __________________
Housing Status Currently not homeless, but at risk of homelessness
Currently not homeless, but was homeless in the last 12
months
Living in car or van
Living in shelter
Living with friends or family, but not paying rent
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Renting or owns own apartment or house
Permanent Supportive Housing
Single Room Occupancy Hotel (SRO)
Living on/at/by Street, Camp, Bridge
Transitional Housing or Residential Treatment Facility
Are you disabled or Yes
chronically ill? No
Unsure
Declined
Do you have HIV? Yes
No
Unsure
Declined
Have you ever been Yes
incarcerated? No
Declined
Are you a current sex Yes, I am a current in person sex worker
worker? (Check all that Yes, I am current online/phone sex worker
apply; only answer if No, I am a former sex worker
comfortable) No, I have never been a sex worker
Declined
Are you a migrant worker? Yes
No
Are you a seasonal worker? Yes
No
Military Status None/No previous experience
Active Duty
Inactive Duty
Reservist
Veteran
Declined
Lyon-Martin Community Health Services is a primary care clinic specializing in providing
healthcare to TGI people and Queer cis-gender women. Are you interested in receiving medical,
mental health, or case management services from us?
Yes
No
Unsure, I would like to learn more
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If yes, we will now create a chart for you in our system. Can we send you a text or email to sign
up for our patient portal, MyChart?
Yes, please text me
Yes, please email me
No, I’m not interested
Is there anything you would like us to know?
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