LA Wildfire Relief Form
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Address
Current Address (where you are currently staying)
Previous Address (if displaced, your address before the wildfire)
City
State / Province
Postal / Zip Code
Proof of Residence
Browse Files
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Choose a file
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of
Were you displaced by the LA Wildfires?
Yes
No
Brief Description of Impact
A short description of how you were displaced
Supporting Documents
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Upload photos, insurance claims, or fire-related notices if applicable
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of
Payment Information
Choose preferred payment method
Direct Deposit
Bank Account Details Required
PayPal/Venmo
Enter email or username
Others?
Please specify
Submit
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