Application for Assistance
Applicants Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Applicants Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Loved One Lost/Injured
*
Relationship to Loved One
*
Incident Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Victims Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief description of Incident (Including Dates and Location)
*
How did you receive this Application?
*
Please provide the name, organization’s name, and contact information of the social worker or victim advocate assisting you. If you are not currently being assisted by a social worker or victim advocate organization, please enter N/A.
*
Are you currently Employed? (Y/N)
*
Yes
No
Are you financially responsible for any minor children? (Y/N)
Yes
No
Are you the sole provider for the household? (Y/N)
Yes
No
Please select the category/Categories of your greatest needs
*
Housing - Mortgage/Rent (up to $2500)
Utilities - Gas/ Power/ Water (up to $1000)
Emergency Travel - (up to $1500)
Family Care - Miscellaneous fund (up to $500)
Food and Household Care - (up to $500)
Memorial and Burial Expenses - (up to $1000)
Other
Please provide support document(s) with you application
*
A personal letter detailing your current family needs or challenges that require support
A copy of any bills you're requesting assistance for, if applicable. Must show name and address
A copy of the death certificate and/or police incident report
A copy of your lease/mortgage, if applicable
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Signature of Applicant
*
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