Requesting assistance for loss of income
This form is for individuals who have lost wages as a result of the coronavirus who are **not artists or service workers** (if you are in one of these categories, see links below).

The information gathered from this intake form will be used to assess need and distribute funds, however filling out this application does not guarantee funds. Individuals will need to show proof of impact (typically a paystub), but physical records of identification will not be kept on file. Additionally, you

Incomplete or invalid information will not be processed.

Please do not include any personal and private information on this form including, but not limited to, medical record numbers or social security numbers.

This application is rolling. We will be in communication when funds will be distributed, but this is dependent also on assessing critical needs as they develop.

Information for artists:

Information for service workers:
Email *
Name *
Other names used
Date of Birth *
Address *
Phone *
Description of financial impact *
Line of work *
See above note about other funds for specific types of workers
If other line of work, please list here. *
Do you have a relationship with officers, employees, or directors of Day One Disaster Relief, or Miel Design Studio? *
If you don't have a relationship with individuals at either organization, select NO.
If yes, please describe.
Please describe your relationship with officers, employees, or directors of Upstream Works, Miel Design Studio or Bull City Rebuilds.
I acknowledge that by submitting this form, I hereby certify that the information provided in this claim form is true and accurate to the best of my knowledge. Submission of this form does not constitute a waiver of any legal rights. Further, I understand that false statements made in connection with this claim will be forwarded to the appropriate law enforcement agencies for possible investigation. I hereby agree that no member of the Board of the Committee, nor any officer or employee of Day One Disaster Relief acting on behalf of the Board or the Committee, shall be personally liable for any action, determination or interpretation taken or made with respect to the fund. I also understand that all information submitted through this form is confidential, will not be shared publicly, and only essential information for record keeping will be kept on file.
Clear selection
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Miel Design Studio. Report Abuse