Mutual Aid Request Form

Mutual Aid Request Form

Please fill out this form to request financial support and provide the necessary details. Please allow up to 30 days for a decision. Mutual Aid Requests are granted one time per calendar year. For 3-day eviction notices, utilities that are already disconnected, and formula requests, please complete this form, then email info@hydrohelpers.net or hhelpers614@gmail.com
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address (if no address please put N/A in all fields)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Amount Requested (USD)*
Reason for Financial Assistance*
Briefly describe your current financial situation*
Preferred Method of Contact*

EmailPhone
Upload Supporting Documents (Proof of bill for requested funds must be uploaded in order for application to proceed) No proof of documentation is subject to automatic denial.*

Cancelof
Should be Empty: