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2021 Immediate Relief Intake - Client Form
This is a pre-application intake form for immediate relief assistance as a result of the 2021 Northern California fires in one of these nine (9) counties: Butte, Glenn, Lassen, Modoc, Plumas, Shasta, Siskiyou, Tehama, and Trinity. Assistance is provided one (1) time per household, if multiple families (i.e. roommates) live within the same home/property, you may need to discuss with your housemates how to divide the relief funds. Financial relief is up to $500 per household that has sustained 50% or more damage. The residence must be your primary residence. Applications may take up to 3 weeks to process. In order to process your application we will need a copy of your ID. If your ID does not have your disaster impacted address (pre-dating the time of the fire), we will need some form of address verification. This may be a utility bill, deed, invoice, lease, W2, paystub or anything else with both your name and address.
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Email *
Last Name *
First Name *
Best Phone Number to Reach You *
Alternative Number to reach you *
Alternate Email *
Which fire impacted you? *
Impacted Street Address *
Impacted Town or City *
Impacted Zip Code *
Did you rent or own the property *
Household Make Up *
How was your home impacted?      (**Please note we are only able to assist individuals who have sustained 50% or more property damage**) *
Do you consent for your information to be shared with other agencies such as disaster case management services and financial assistance programs to help those affected by wildfire meet their immediate and long term needs? (This includes agencies such as Salvation Army, United Way, Northern Valley Catholic Social Services, Tzu Chi Foundation, McConnell Community Foundation, and others.)  **Please note: we will NOT share your information with anyone other than disaster services agencies** *
Thank you for your application:
Please note that a disaster services agent from United Way will be emailing you a link for uploading your ID and proof of disaster impacted address. If you cannot use the link, we will work with you to find the best method of obtaining documentation.
A copy of your responses will be emailed to the address you provided.
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