CCC FIRE RECOVERY FINANCIAL ASSISTANCE INTAKE

Who is completing this form?* This field is required.This grant assistance is intended for faith communities

First Name

Last Name

What is the name of your church, faith community, or organization?* This field is required.If not applying as an institution, please state the faith community you attend or are affiliated with.

What funding are you applying for?* This field is required.Select the type of request

Direct Assistance for Clergy (personal, not church)

Faith Community/Church Ministry Grant (i.e. operations, ministry)

Direct Assistance for Individual/Family (housing, job loss, tools, auto, etc)

Community Organization Grant (501c3)

In which area(s) are your requesting support?* This field is required.Please note that this funding is specifically for fire-impacted needs only

Basic Needs: Food, Gas, Gift Cards

Employment Income Replacement

Job Related Loss (i.e. supplies, tools, uniforms)

Temporary Housing (i.e. hotel stay)

Security Deposit to obtain housing

Rental Assistance

Major Household: Furniture, Appliances, etc.

Minor Household: Move-in Kit (Items for Kitchen, Home/Office, Tool)

Transportation (vehicle repairs, rideshare or public transit pass)

Other

What is your Eaton fire impacted address?

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Do you own or rent at the impacted address?

I own

I rent (my name is on the lease)

Resident only (neither own or officially rent)

What type of damage did you experience at your residence?* This field is required.

Total Fire Damage (Loss)

Partial Fire Damage (Repaired/Remedied)

Partial Fire Damage (Still Displaced)

Minor Smoke/Wind/Heat Damage

What best describes your household?

Live alone

Live with spouse/partner (no children)

Live with spouse/partner and children

Single parent with child(ren)

Extended family (e.g. parents, grandparents, adult siblings, grandchildren, etc.)

Live with roommates or non-family members

Other

How many people are in your household? Note: A household is defined as you and other adults (excluding roommates) living with you who contribute financially to the household, and any dependents who you are financially responsible for:

Enter total number of adults and children (if applicable) in the household

AdultPlease enter the number of adults in the household (18 years +)

# Adults 18+

ChildrenPlease enter the number of children in the household (under age 18)

#Children under 18

Which best describes your insurance status?

Insured-Home

Insured-Renter's

Underinsured

Not insured

Which best describes your current housing situation?

Housing Insecure: Unsheltered /living in a vehicle

Living in hotel/motel/shelter

Staying with friends or family temporarily

Renting a temporary home or apartment

Renting a new permanent home or apartment

Purchased a new home

Other

What was your previous monthly rent or mortgage?

Monthly

What is your current monthly rent or housing cost?

Monthly

What best describes your future plans for housing ?

Searching for a home or apartment

Placing an RV or temporary home on my lot

Relocating to another city or state

Do you plan to rebuild?

Yes

Unsure

What information would you need to feel secure in rebuilding?

Which best describes your employment?

Clergy, Full Time

Clergy, Bi-Vocational

Employed Full-Time

Employed Part-Time

Entrepreneur/Self-Employed/Labor

On unpaid leave

On paid leave

Not employed

Other

If not employed, please describe the reason.

Health Issue

Disability

Job Loss

Caregiver

Retired

Full-Time student

How was your income/resource been impacted by the fire?

Does your church/faith community rent or own?* This field is required.Please respond for your location prior to the wildfires.

Own

Rent

How was your building or location impacted by the Eaton fire?* This field is required.

Total Loss

Smoke or Wind Damage (but we've returned)

Smoke or Wind Damage (still displaced)

Partial Loss

No Damage

How have your finances been impacted as a result of the Eaton fire?* This field is required.(i.e. attendance, tithes & offerings, donations)

In which area(s) are your requesting support?* This field is required.Select all that apply

Church Operations/Ministry Support (equipment, transportation, vestments, etc)

Church Relocation (venue fees, Uhaul, storage, etc)

Facility Repairs/Clean-up/Smoke Remediation

Wellness/Mental Health Support/Staff Resilience & Care

Technology & Communications (replace lost computers, equipment, etc)

Recovery related program & events (i.e. food, rentals, etc.)

Other

How would you use grant funding?* This field is required.Please give a very brief general overview of what you hope to accomplish or who you hope to serve.

Does your organization rent or own your location?* This field is required.

Own

Rent

Who does your organization serve?* This field is required.Please list any specific populations your support

How have your finances been impacted as a result of the Eaton fire?

In which area(s) are your requesting support?* This field is required.Select all that apply

Operations Support

FacilityRepairs/Clean-up/Smoke Remediation

Wellness/Mental Health Support/Staff Care (communal events)

Technology & Communications (replace lost computers, equipment, etc)

Supplies for Relief or Recovery related events (i.e. food, rentals, etc.)

Support/expand an existing program

Other

How will you use grant funding?Please give a very brief general overview of what you hope to accomplish or who you hope to serve.

Please further describe your situation and request in detail (including amounts if available) :* This field is required.Please delineate costs if requesting multiple areas of support

Amount Requested* This field is required.This is not a guarantee but allow us to understand the need and guides us in fulfillment.

What is your current mailing address?* This field is required.

Street Address

City

State / Province

Postal / Zip Code

Country

What is your email address?

example@example.com

Phone NumberBest phone number to reach you

Area Code

Phone Number

Would you like to submit another request?* This field is required.

YESNO

CCC FIRE RECOVERY FINANCIAL ASSISTANCE INTAKE