Fire Relief Assistance Request

Language:

English

Your Full Name

Your Address

Your Phone number

Your Email address

List all jobs lost, wages and contact phone number's:

Include job title, number of hours worked per week, years employed and wages.
If you have more than one employer, add their names and phone numbers here.

Number of people living with you:

(Names and Ages of everyone in your house - INCLUDING YOURSELF)

Other household income :

(others contributing to the household income and amount)

Total monthly household income:

Monthly rent/mortgage:

Total monthly utilities:

Other monthly assistance you receive :

(EDD unemployment benefits, federal and state programs, church, SNAP, TANF, Medicaid, Healthy Families, Cal Works, CHIP, extended family help, etc.)

Please select

Please describe your current situation, what your needs are, and why:

Monthly employee income before fire:

Monthly employee income after fire:

2023 yearly earnings

How are you seeking additional income/jobs? Please describe in detail:

Do you have new jobs coming, has your employer helped with your job search, have any of your employers continued to pay you?

Employer's status

Clear choice

My employer lost their home to the fire

My employer lost their business to the fire

My employer's home was significantly damaged

I'm self-employed (please be prepared to show proof of income such as 2023 tax return)

Other: Please describe below

Please describe employer's loss:

Employer Verification

We will need to verify your employment with your employer. We will call or email them directly on your behalf.

Employer First / Last name

Employer Phone number

Employer Email address

Employer's Affected Property Address

Replace this with a title or description

Verification