Homelessness Assistance Form

2. First name (head of household)*

3. Last name*

5. Phone number*

6. Household size*
   -- Select One --1234567 or more

8. Email address:*

10. Please re-enter email address to verify it was entered correctly above:*

12. Please select where you slept last night:*

    1. Shelter
    2. Extended Stay/Motel/Hotel paid for by a charitable organization (not self-paid)
    3. Other

14. What is your household's hardship?*

    1. Loss of job due to lay off from Covid-19
    2. Reduced Work Hours due to Covid-19
    3. Myself or a member of my household contracted Covid-19
    4. Had to be quarantined due to someone in my household or job contracting Covid-19
    5. Other

16. If you chose "Other" above, please indicate your hardship here:

18. What is your preferred method of contact to receive official correspondence?*

    1. Email address
    2. Regular Postal Mail

Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field