Needs List Form Applicant

Eaton/Palisades Fire Aid Assistance Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Contact phone number
Please enter a valid phone number.
Needs List
The Eaton/Palisades wildfire caused significant damage and displacement in the affected areas. Please let us know how we can help you.
Immediate Needs

Temporary Housing / Emergency ShelterFinancial AssistanceFood and WaterMedical CareChildcare
Essential Supplies (clothing, toiletries)TransportationHealth supportMental Health SupportPetcare
Long Term Needs

Debris Removal/Property CleanupRebuilding AssistanceLegal AssistanceInsurance AssistanceInformation about Resources/Benefits
Other Needs/Comments
Please describe any other specific needs you have that are not listed above:
Verification and Submission*

I certify that the information provided is true and accurate to the best of my knowledge.
Should be Empty:

Eaton/Palisades Fire Aid Assistance Form