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* 1. Date of Application

Date
Time

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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?

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.

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* 16. Applicant’s Signature

T