COVID-19 Assistance - Cloud 9 Charities

Applicant 1 First Name*

Applicant 1 Last Name*

Applicant 2 First Name*

Applicant 2 Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Email*

Financial Information

Please try and be as accurate as possible, the more information that we have the better.

Total Monthly Household Income*

Total Monthly Rent/Mortgage*

Utilities (electric)*

Gas (home)*

Cable/Internet/Home Phone*

Mobile Phone(s)*

Groceries*

Car Payment*

Auto Insurance (If applicable)

Gas (Car / Average Monthly)*

Medical Expenses

Prescription RX Expenses

Other Monthly Expenses not Listed Above

What is the total amount of your request?*

Please enter a number from 1 to 1000.

Explain what caused your hardship and the list expenses that have been a factor in your current situation?*

List the bills and expenses you are asking for assistance with. Be specific and itemize with dollar amounts if possible please.*

Have You Already Applied for Financial Assistance?*

If you answered Yes to the question above who have you received financial assistance from?

Are you directly or indirectly related to any board member at Cloud 9 Charities?*

Please provide a name of someone as a reference who has knowledge of your current situation.

Name*

First Last

Phone*

Relationship to You*

Consent

I agree that the information provided above is as accurate as possible.

Name

This field is for validation purposes and should be left unchanged.