Pitkin County Emergency Assistance Request
Please use this form to request assistance from Pitkin County due to hardships your household is experiencing due to the impact of COVID-19. Examples of assistance that may be available include but are not limited to: rental/mortgage assistance, utility assistance, emergency food assistance, household supplies, and transportation assistance. We request that you do not request assistance for any expenses that are being covered by other agencies. Please leave a working phone number so that we can contact you to conduct a brief interview to collect the information necessary to determine what/which resources may be available to you. We will do our best to contact you within 48 hours. Thank you and take care.
What is your full name? *
What is your date of birth?
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In which County do you live? *
What is your physical address? *
What is your mailing address? We will need this information to send your benefits if your application is approved. If your mailing address is the same as your physical address, please enter "Same". *
How many people are in your household? This refers to how many people are in your home that will be receiving assistance. *
Are there any children under the age of 18 in your household? *
Are you and/or members of your household lawfully present in the United States? Please note that if your answer is "No", that does not mean that you will not be eligible for assistance. *
What is your phone number? *
What is your email address? To limit in-person contact, please provide an email address where we can send correspondence or requests for information.
What is the CURRENT income for your household? If you have been laid-off and are waiting to return to work or for unemployment benefits that you are not currently receiving, you can say your income is $0.00 at this time. *
Please indicate how much cash on hand or checking/savings you have available at this time. *
What type of assistance to you need at this time? *
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