COVID-19 Emergency Management Fund Application Please enable JavaScript in your browser to complete this form.Applicant Identification and Contact InformationIf financial assistance is disbursed, each applicant will be required to submit a copy of her/his state issued identification and social security card. Name *FirstLastEmailPhone *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSex--MaleFemaleBirthdateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship Status--MarriedSingleDivorcedHousehold InformationHow many children are in the household address you have provided?What are the ages of the children living in this household?How many adults are in the household address you have provided?Do you have any disabilities related to this application?--YesNoIf you have disabilities related to this application, please list each disability.Employer Information & Income and ExpensesWe will need to contact your employer to verify your employmentCompanyOwner / Manager NameFirstLastOwner / Manager Name PhoneCompany AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCurrent Employment Status--Full-time Part-time UnemployedOtherMonthly income from employmentNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Upload paystub * Click or drag files to this area to upload. You can upload up to 3 files. Be sure to attach your latest paystub. Paystubs dated before February 2020 will not be accepted. Other AssistanceDo you currently receive government assistance?--YesNoIndicate which type(s) of assistance you receive. Please check all that apply.Supplemental Nutrition Assistance Program (SNAP)MedicaidMedicareSocial SecuritySupplemental Security Income (SSI)Temporary Assistance for Needy Families (TANF)Veterans BenefitsWomen, Infants, and Children (WIC)Monthly income from government assistanceNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly income from other sources (alimony, child support, etc.)Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251ExpensesMonthly rent/mortgageNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly utilities (electricity, gas and water)Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly car paymentNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly car insuranceNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly childcareNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly phone billNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly cable InternetNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Monthly miscellaneous expensesNumbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Explanation of Assistance RequestWhich type of assistance are you seeking? *--RentalMortgageUtilityHow much assistance are you requesting? *Please note that a maximum of $200.00 may be distributed to each household.Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Mortgage Company NameFinancial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Copy of recent mortgage statement. Click or drag a file to this area to upload. Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Be sure to provide a copy of the latest billing statement. This form can accept a picture from your phone or scanned copy as a PDF.Landlord NameFirstLastFinancial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers.Landlord PhoneCopy of lease. Click or drag a file to this area to upload. Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Be sure to provide a copy of the latest billing statement. This form can accept a picture from your phone or scanned copy as a PDF.Utility Company NameFinancial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Utility Company Account NumberFinancial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Copy of recent utility bill Click or drag a file to this area to upload. Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers. Be sure to provide a copy of the latest billing statement. This form can accept a picture from your phone or scanned copy as a PDF.Payment amount due to service provider (landlord, mortgage company or utility provider):Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251Due date of next paymentReason for financial assistance.Example: Furloughed during restaurant shutdown because of coronavirus outbreak.Comment or MessagePlease add any other information or comment you'd like to provide here.NameSubmit