Request edit access
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.
Sign in to Google
to save your progress.
Best Phone Number to Reach You
Alternative Number to reach you
Which fire impacted you?
Impacted Street Address
Impacted Town or City
Impacted Zip Code
Did you rent or own the property
Temporarily Living with Friend/Family Member
Living in a trailer/RV on a property of landlord/friend/family member
Household Make Up
Single Adult - no children
Two or more adults - no children
Single adult with 1 or more minor
Two or more adults with 1 or more minor
How was your home impacted? (**Please note we are only able to assist individuals who have sustained 50% or more property damage**)
Evacuated, but sustained no damage
Structure was completely destroyed
Structure sustained significant damage (50% or more)
My property/structure sustained some damage (Less than 50%)
I am not sure how damaged my residence is
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 operating under the NorCal Community Recovery Team coordination 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.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service