Stanislaus Fund Application for Hurricane Ida Assistance

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* 1. Date of Application

Date / Time

Date

Time

AM/PM

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* 2. Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. Job Title

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* 4. Department

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* 5. Location

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* 6. How many hours do you work per week?

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* 7. Are you considered

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* 8. Please describe what circumstances have occurred that resulted in your hardship? (Be very specific to avoid delays in review of your application)

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* 9. What is your hardship need? (Please provide supporting documentation below.)

Temporary Housing

Food and Water

Basic Needs (clothing, diapers, formula)

Transportation or Gas

Medication expenses for associate, spouse, or dependent(s); provide unpaid medication
expenses

Utility

Property Damage (please explain below)

Other (please explain below)

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* 10. Please describe property damage or other needs from Question 9:

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* 11. How many people are living in your household?

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* 12. Amount requested to help with hardship?

Under $100

Under $250

Under $500

Under $1,000

$1,000 and above

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* 13. Is this your first request under the Stanislaus fund?

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* 14. What are your options if your request is not approved?

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* 15. How would you like to be contacted?

By phone

By email

By submitting the request, I attest and agree that all the information on this form is true and accurate to the best of my knowledge. I further authorize sharing my information with the vendor or other agency who needs to know for
providing this assistance.

Stanislaus Fund Application for Hurricane Ida Assistance

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* 1. Date of Application

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* 2. Address

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* 3. Job Title

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* 4. Department

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* 5. Location

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* 6. How many hours do you work per week?

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* 7. Are you considered

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* 8. Please describe what circumstances have occurred that resulted in your hardship? (Be very specific to avoid delays in review of your application)

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* 9. What is your hardship need? (Please provide supporting documentation below.)

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* 10. Please describe property damage or other needs from Question 9:

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* 11. How many people are living in your household?

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* 12. Amount requested to help with hardship?

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* 13. Is this your first request under the Stanislaus fund?

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* 14. What are your options if your request is not approved?

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* 15. How would you like to be contacted?

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* 16. Applicant’s Signature