CERV 2020 Wildfire Support Question Title * 1. Tell us about yourself Name Current Address City/Town State ZIP/Postal Code Email Address Phone Number Question Title * 2. What do you need help with? Check all that apply. Gas Rent or rent deposit Mortgage assistance Lost wages Home repairs Hotel costs (includes reimbursements for) Food Utilities Medical bills (fire related) Other (please specify) Question Title * 3. What was your address prior to the fire? (The address that was affected by the fire.) Address Affected by the Fire City/Town Email Address Phone Number Question Title * 4. Including you, how many people are there in your family (that live in the same home)? Question Title * 5. Approximately, how much money do you need? (We may not be able to fulfill this request, but it's helpful for us to know.) Thank you for sharing this information with us. We will contact you within the next few days if not sooner. Done