RHF Crisis Fund Application

RHF Crisis Fund Application
Winter Storm Fern Applicants: Please note that additional documentation and responses may be requested. Updates will be made here or you will be contacted.
Applicant's Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Place of Citizenship

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Since:
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
NRHA Member Number*
Years as an NRHA member
Are there other NRHA members in your household?*

YesNo
If yes, please put their names here:
Describe hardship (in detail)*

0/2000
Annual Gross Family Income (per year)*
Annual Net Family Income (per year)*
Number of children or dependents comprising family of applicant:*
Insurance applicable to crisis. Provide a verifiable description of coverage and exclusions, if applicable:
Deductible and/or amount not covered by insurance:
Please provide any other sources of support available to the applicant including GoFundMe, American Red Cross, FEMA, similar international aid, and others:
Signature (applicant or family representative)*

Clear
Date Signed*

MonthDayYear
Date
**Please attach documentation in support of application. This can be photos of accident/disaster, copies of bills, medical crisis verification, and estimates of income loss. All information will be viewed anonymously by the RHF Crisis Fund Committee to determine eligibility of Crisis Fund payments. Refrain from using the applicant’s name and instead use pronouns to protect anonymity in this description.

Cancelof
Should be Empty:

RHF Crisis Fund Application

Winter Storm Fern Applicants: Please note that additional documentation and responses may be requested. Updates will be made here or you will be contacted.