Emergency Relief Grant Application

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This program requires that there has there been a proclamation of natural disaster by a local, regional, state or federal government entity covering the area of the employee(s) lost home(s). This Fund can assist people who have lost their homes (rent or own) to emergency. Resources available from this Fund are limited and are distributed on a first-come, first-served basis.

Name of Impacted Worker

First Name

Last Name

Employer Name

Please tell us the name of the impacted worker's employer.

Applicant Name

Who is this filling out this form?

First Name

Last Name

Applicant Email

Applicant Phone Number

What is the best number to reach you?

(###)

###

####

Supervisor Name

If you are not the employee's supervisor, please provide the supervisor's name.

First Name

Last Name

Supervisor Email

Please provide the email of the impacted worker's supervisor, if other than applicant.

Beneficiary Address

Where should we send the check?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permission to Use Image

May we use an image of the impacted worker/family/property on our website, social media and in CTF communications?

Yes

No

Disclosure and Agreement

I understand that an emergency declaration by a local/state/federal government is required for the qualifying event. I understand that funds available are limited and will be distributed on a first-come, first-served basis. Grants from this Fund are considered gifts and are not taxable as income. I understand that this grant cannot be disbursed without the approval of the employee's supervisor. In the case of Caltrans, this requires a Deputy District Director or Division Chief approval. For other organizations, a similar level of authorization is required.

I agree

Circumstances

Please provide a brief description of the emergency event.