COVID19 DISTINCT INITIATIVE ASSISTANCE FORM

Request Date *

Requested Amount: *

Address, City, State, Zip: *

Contact Name: *

First

Last

Contact Phone: *

Email *

Facebook URL:-----> Enter "None" If Not Applicable *

Tell Us What Kind of Assistance You Need. Please be Specific and Detailed *

Tell Us What Caused Your Need for Assistance. Please be Specific and Detailed Ex: Layoff, Sickness. *

Test

File Upload-----> You Must Upload Supporting Documents and a Photocopy of Your Drivers Lic. *

Click or drag files to this area to upload. You can upload up to 4 files.

Do you agree to sign a Consent for Release Form ? *