RVA Family Crisis Fund Intake Form

Family Crisis Fund Intake Application

Please complete the following form for emergency Family Crisis Funds. A Family Crisis Fund Team Member will contact you within three to five business days.
Eligibility Criteria

We request that each partner agency/organization review our eligibility criteria before submitting a need to the Family Crisis Fund Team. We understand that each individual's circumstances are unique. Therefore, our team will work diligently to review each application. Eligible residents will need to provide a government-issued ID to verify their identity.
Please check all that apply
Resident Information
The City of Richmond's Family Crisis Fund is dedicated to supporting eligible Richmond residents who are facing financial barriers. To verify if a resident lives within the City of Richmond limits, please click here and enter the address of their current residence.

If their address is outside of the City of Richmond limits, please direct them to their local Social Services or Human Services Department or use 211.org to locate additional resources.
Resident's Name

First NameLast Name
Resident's Date of Birth

MonthDayYear
Date
Resident's Email Address
example@example.com
Resident's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Resident's Address (Note: If homeless, add shelter address.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Race
Ethnicity
What is your marital status?
Are you a veteran?
What is your employment status?
Total number of people in your household
Which best describes your total household income?
Financial Need Requested (Proof will be required)

Other
My household has experienced negative economic impact(s) in the following ways -- briefly describe how the resident has been economically impacted, and briefly describe how these funds will be used (For example: These funds will assist with paying three months of past due energy bills, and one month of child care due to a health emergency.)
Has the resident received assistance from another funding or agency source? List sources of assistance in the section below (e.g., SNAP benefits - (notate monthly allotment), TANF - (notate monthly allotment).
To be considered for the City of Richmond Family Crisis Fund, all other forms of possible assistance must be applied for and exhausted. Failure to completely document this in the following section and attach supporting documentation will result in delay or denial of the application.
Please securely email any respective bills or verification documentation (e.g., scanned copy of resident's government-issued ID) to RVAFCF@humankind.org.
Referring Agency/Organization
Name of Referring Agency/Organization
Referring Agency/Organization Staff Name

First NameLast Name
Referring Agency/Organization Staff's Email
example@example.com
Referring Agency/Organization Staff's Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Agency/Organization ID
I have reviewed the Family Crisis Fund process and eligibility criteria.
Should be Empty:

Family Crisis Fund Intake Application

Eligibility Criteria

Resident Information

Please securely email any respective bills or verification documentation (e.g., scanned copy of resident's government-issued ID) to RVAFCF@humankind.org.

Referring Agency/Organization