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

1. Date of Application

2. Address

3. Job Title

4. Department

5. Location

6. How many hours do you work per week?

7. Are you considered

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

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

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

11. How many people are living in your household?

12. Amount requested to help with hardship?

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

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

15. How would you like to be contacted?

16. Applicant’s Signature