Canal Alliance Emergency Fund

Contact Information

First Name *

Middle Name

Last Name *

Birthdate * 🛈 +

Street Address *

City *

State *

Zip Code *

Mobile *

Do you have an email address *

Yes

No

Email Address *

Gender *

Sexual Orientation *

Marital Status *

Children? *

Country of Origin *

Ethnicity *

Primary Language *

Employment status *

Employment Industry *

COVID-19 Impact

Have you received Canal Alliance services in the past? *

How long have you been in the US? *

Do you have an active bank account in the United States? *

Reason for Emergency Assistance *

Reason for Emergency Assistance - Other *

Do you qualify for any federal relief programs? * 🛈

How much did you make in total in the year 2019? * 🛈

How many people are in your household (including yourself)? * 🛈

How many of the people in your household are minors (under the age of 18) *

What was your average monthly income prior to the coronavirus (COVID-19) pandemic? *

What is your current average monthly income? *

Please upload a photo of a document or envelope that includes your name and address, such as a PG&E bill addressed to you. This is to make sure if we mail you a check, it arrives to the correct address. Please include in the photo your name and address, and don't include any confidential information such as account numbers. *