Call us: 877-250-9025

Emergency Financial Assistance

Emergency Financial Assistance Form

Name
First Last
What county do you currently live in?*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email
Enter Email Confirm Email
Date of Birth*
Date Format: MM slash DD slash YYYY
How did you hear about us?
Marital Status
Highest Education Level
Active Military?
Military Veteran?
Are you disabled or disabled dependent?
What is your race?
What is your ethnicity?
Indicates if you are Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Gender
- Male
- Female
What is your English proficiency level?
Do you rent or own?
Would you like more information on becoming a first-time homebuyer?
What is the size of your household?
The number of people currently residing in your household (e.g. the number of people living in the house at the time service was provided).
Please enter a number from 0 to 50.
What is your annual family or household income?
The household gross (pre-tax) income during the year as reflected in your loan or grant application.
Please enter a number from 0 to 500000.
Privacy Notice Opt-out? (By opting out, you may not be eligible for some services)
- Yes
- No
Please describe your financial emergency.
Please upload the following documents to ensure your intake appointment goes smoothly.
Housing Assistance (Rent/Mortgage)
Drop files here or
Utility Assistance (Bill)
Drop files here or
Access to health care appointment and medications (Bill)
Drop files here or
Employment assistance (Description)
Drop files here or
Childcare costs (Bill)
Drop files here or
Other critical unmet need (Description)
Drop files here or
Identification
Drop files here or
Proof of Residency
Drop files here or
Letter Describing the Emergency due to COVID-19
Drop files here or
Signed Disclosures
Drop files here or
(Click Here to download disclosures)