CORD Cares Assistance Application

CORD Cares Foundation Assistance Application

To help us determine what is needed to assist you, please fill out the form below and provide as much as information as possible.
Applicant Name

First NameLast NameDegree
Email
example@example.com
Cell Phone

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Program Name
Program Director Name

First NameLast Name
Program Director Email
example@example.com
Program Director Phone

Area CodePhone Number
Amount Requested - Max $500.00
Funds available on a first come, first served basis.
Please tell us how you were impacted (500 words or less)

0/500
Upload Your Completed W9 Form

Browse Files

Cancelof
Upload Supporting Documentation for Amount Requested (Receipts or Estimates

Browse Files
CORD prefers receipts where available. Cancelof
I do hereby make a request for financial assistance from the CORD Cares Foundation. The financial assistenace is requested as a result of significant property loss. I do hereby certify that funds I am receiving from the CORD Cares Foundation will be used for unmet needs. (For example, if a CORD member received assistance from FEMA to repair a roof, the funds received from the CORD Cares Foundation could be used to pay for other needs, such as debris removal, other home repairs, replacement of appliances, clothing, furniture and other contents, etc.)
Date

MonthDayYear
Date
Signature
Should be Empty:

CORD Cares Foundation Assistance Application