BRCA CARES Application
Name:
*
First and Last Name
Phone:
*
Primary Contact
Email:
*
example@example.com
Are you related to anyone at BRCA agency?
*
Yes
No
If you answered "Yes" to the above question, who are you related to at BRCA?
Name of related BRCA employee
Are you a Burke, Caldwell, or Rutherford county resident?
*
Yes
No
Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip Code
Have you experienced a loss or reduction of income due to COVID-19?
*
Yes
No
Household Income Before COVID-19
*
90 Day Gross Income (Prior to taxes)
Weekly:
Monthly:
Current Household Income
*
90 Day Gross Income (Prior to taxes)
Weekly:
Monthly:
Please describe the changes to your income due to COVID 19:
*
What are the financial hardships (i.e. increased expenses) that you are experiencing related to COVID-19?
*
Funds Requested
Funds may be used flexibly to support individuals and families with financial disruption directly related to this crisis. We may not be able to fund the entire amount of all requests, but we will try to meet at least some of the needs of each eligible application. Please indicate the amount you are requesting in each of the following areas.
Rent/Mortgage/Security Deposit
Basic Telecommunication Utilities (i.e. internet for families with school aged children)
Utility Expenses
Childcare Expenses
Food Expenses
Other expenses related to basic needs
Describe the relationship of the applicant to a person affiliated with BRCA (if applicable.)
Name of family member and relationship to applicant
Media Consent Release:
I agree to participate in interviews, photography, or videos for the purpose of highlighting BRCA CARES Program. This consent grants permission to edit, use and reuse information, photographs or videos in print, broadcast, or other forms of media. This release applies to all household members.
Do you agree?
*
Yes
No
I certify that all information in this application is true and accurate. I give permission to BRCA to verify all information provided. I understand the BRCA CARES NC program funding is a one-time subsidy to prevent evictions, foreclosures, disconnections of utilities, etc. (related to COVID) that does not require repayment.
Signature
*
Preview PDF
Submit
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