Applicant Information ONLY One Application Per Household – First Name Last Name Phone Number ethnicity and race information is optional. it is requested to assure the benefits are given without regard to race, color or national origin. your answers will not affect your eligibility or funding support. Check this box if you do not want to give United Way information about your race or ethnicity Ethnicity/Race are you Hispanic, Latino or Spanish Origin? YES NO White American Indian/Alaskan Native Black/African American Asian/Pacific Islander Address Where Damage Occurred (write n/a if not applicable) Street Address Apt Number City Zip Code Current Contact Information Street Address Apt Number City Zip Code Email: PARTY VENDOR INFORMATION Name: Number Address: Amount Requested $ Proof of Primary Residence at Time of Fire is Required. Please Provide Copy of One of the Following: Tax Return Driver’s License AGENCY USE ONLY Voter Registration Photo ID Is address in the fire area: YES NO Utility Bills Rental Agreement Indicate the Type of Assistance That Describe your Need and Indicate the Amount of Funds You Are Requesting. You are Requesting You Will Need to provide Documentation to Justify Your Request. If Request is Approved, check will be made to identified third Party Vendor. Housing Assistance ☐ Habitability of Home ☐ ☐Livelihood/Income/Employment (Tools, uniform, transportation) Vehicle Repair/Replacement ☐ Other: ☐ Insurance Information Explain any Gaps in Your Insurance Coverage Related to Your Request Homeowners Renters Auto Other: INCOME AND FAMILY SIZE ELIGIBILITY CRITERIA FOR THOMAS FIRE RELIEF FUND Additional eligibility requirements may apply and basic criteria may change based on community needs and available funding.
Applicant Information – ONLY One Application Per Household First Name Last Name Phone Number ethnicity and race information is optional. it is requested to assure the benefits are given without regard to race, color or national origin. your answers will not affect your eligibility or funding support. Check this box if you do not want to give United Way information about your race or ethnicity Ethnicity/Race are you Hispanic, Latino or Spanish Origin? YES NO White American Indian/Alaskan Native Black/African American Asian/Pacific Islander Address Where Damage Occurred (write n/a if not applicable) Street Address Apt Number City Zip Code Current Contact Information Street Address Apt Number City Zip Code Email: PARTY VENDOR INFORMATION Name: Number Address: Amount Requested $ Proof of Primary Residence at Time of Fire is Required. Please Provide Copy of One of the Following: Tax Return Driver’s License AGENCY USE ONLY Voter Registration Photo ID Is address in the fire area: YES NO Utility Bills Rental Agreement Indicate the Type of Assistance That You are Requesting Describe your Need and Indicate the Amount of Funds You Are Requesting. You Will Need to provide Documentation to Justify Your Request. If Request is Approved, check will be made to identified third Party Vendor. ☐ Housing Assistance ☐ Habitability of Home ☐Livelihood/Income/Employment (Tools, uniform, transportation) ☐ Vehicle Repair/Replacement ☐ Other: Insurance Information Explain any Gaps in Your Insurance Coverage Related to Your Request Homeowners Renters Auto Other: INCOME AND FAMILY SIZE ELIGIBILITY CRITERIA FOR THOMAS FIRE RELIEF FUND Additional eligibility requirements may apply and basic criteria may change based on community needs and available funding.
United-Way-Application-with-Logo-6-10-18-ENGLISH-VERSION.docx