Healing Households Assistance Application: Emergency Relief
Do you and your family need immediate financial assistance? If you don’t find the money soon you will be without life’s basic necessities? (Food, lights, shelter, transportation, etc.) We’ve been there. Let us lend a helping hand. *******Note this grant is intended for temporary emergencies ONLY! This grant is not intended to be reoccurring. Our hope is to assist you financially and help you become self-sufficient.
What is your name?
*
First Name
Last Name
What is your email address?
*
example@example.com
Please provide your best contact number.
*
Please enter a valid phone number.
Is this your first time applying for a Healing Households Emergency Relief grant?
*
Yes
No
Please describe your immediate need?
*
Please describe the events that led up to you needing this immediate assistance. (Laid off, change in circumstances, loss of family member, etc.)
*
How much are you in need of?
*
When do you need it by?
*
-
Month
-
Day
Year
Date
Please upload supporting evidence of your need (bill, receipt, etc.)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What steps will you implement to avoid needing immediate assistance in the future?
*
Submit
Should be Empty: