COVID-19 Emergency Management Fund Application

Applicant Identification and Contact Information

If financial assistance is disbursed, each applicant will be required to submit a copy of her/his state issued identification and social security card.
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Household Information

Employer Information & Income and Expenses

We will need to contact your employer to verify your employment
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
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 Assistance

Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251

Expenses

Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251

Explanation of Assistance Request

Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers.
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.
Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers.
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.
Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers.
Financial assistance granted will be disbursed directly to landlords, mortgage companies, or utility providers.
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.
Numbers only. No decimals or dollar signs. Round up to a whole dollar amount. Example: 1251
Example: Furloughed during restaurant shutdown because of coronavirus outbreak.
Please add any other information or comment you'd like to provide here.

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