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Homelessness Assistance Form
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First name (head of household)
-- Select One --
7 or more
Please re-enter email address to verify it was entered correctly above:
Please select where you slept last night:
Extended Stay/Motel/Hotel paid for by a charitable organization (not self-paid)
What is your household's hardship?
Loss of job due to lay off from Covid-19
Reduced Work Hours due to Covid-19
Myself or a member of my household contracted Covid-19
Had to be quarantined due to someone in my household or job contracting Covid-19
If you chose "Other" above, please indicate your hardship here:
What is your preferred method of contact to receive official correspondence?
Regular Postal Mail
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