APPLICATION FOR CORONA VIRUS ASSISTANCE

PART 2 - HUSBAND EMPLOYMENT:
ARE YOU WORKING NOW?*

YESNO
EMPLOYER NAME:*
SALARY$*
DID YOU WORK BEFORE THE PANDEMIC?*

YESNO
EMPLOYER NAME BEFORE PANDEMIC:*
SALARY BEFORE PANDEMIC:*
ARE YOU COLLECTING UNEMPLOYMENT?*

YESNO
HOW MUCH ?*
WHY NOT?
HAVE YOU/ WILL YOU BE RECEIVING GOVERNMENT STIMULUS CHECK DUE TO CORONA VIRUS?*

YESNO
HOW MUCH ?*
WHY NOT?

PART 3 - WIFE EMPLOYMENT:
ARE YOU WORKING NOW?*

YESNO
EMPLOYER NAME:*
SALARY$*
DID YOU WORK BEFORE THE PANDEMIC?*

YESNO
EMPLOYER NAME BEFORE PANDEMIC:*
SALARY BEFORE PANDEMIC:$*
ARE YOU COLLECTING UNEMPLOYMENT?*

YESNO
HOW MUCH ?*
WHY NOT?
HAVE YOU/ WILL YOU BE RECEIVING GOVERNMENT STIMULUS CHECK DUE TO CORONA VIRUS?*

YESNO
HOW MUCH ?*
WHY NOT?

PART 4 - OTHER PERTINENT QUESTIONS:
IN WHAT WAY HAS THE STAY AT HOME PANDEMIC AFFECTED YOUR FAMILY FINANCIALLY?*
HAVE YOU/WILL YOU BE RECEIVING OTHER GOVERNMENT FINANCIAL SERVICES DURING THIS TIME?*

YESNO
PLEASE INDICATE WHICH SERVICES*
AMOUNT:*
REFERENCES: AT LEAST TWO (MUST PROVIDE PHONE NUMBER AND YOUR RELATIONSHIP TO THEM):
REFERENCE #1
Name*

First NameLast Name
RELATIONSHIP:*
PHONE #:*
REFERENCE #2
Name*

First NameLast Name
RELATIONSHIP:*
PHONE #:*
IF APPROVED WHERE SHOULD THE CHECK BE MAILED TO:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

REFERENCE #1