Recovery Support Program Lottery Registration
Registrant Information
First Name
Last Name
Email Address
State Receiving Treatment
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Ethnicity:
Please select...
American Indian from South or Central America
American Indian or Alaska Native
Asian
Black or African American
Latinx or Hispanic
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White - European
Other
Prefer not to Say
Which expense is your greatest financial stressor?
Please select...
Groceries
Rent/Mortgage
Contact Information