Application for COVID-19 Support
Embrace Relief has launched a campaign to assist those who have or will be losing their income due to the COVID-19 pandemic. This campaign seeks to help those who are experiencing financial loss due to the pandemic regardless of legal status including American citizens, immigrants, asylum seekers and undocumented immigrants. We are offering assistance to those who are struggling to pay for food, rent payments, utilities, medications and other basic necessities.

**PLEASE NOTE: Although we cannot promise that we will be able to help everyone who applies, we will try our very best to offer as much support to as many people as we can.
Full Name *
Your answer
Phone Number *
Your answer
Email address *
Your answer
Address *
Your answer
State *
Your answer
Age *
Your answer
What is your legal status? Your response to this question will not affect your eligibility to receive assistance in any way.
Assistance Needed (please check however many boxes you need support with) *
Required
Are you currently working? *
If yes, how much are you earning monthly?
Your answer
Did you lose your job due to the Coronavirus pandemic? *
If yes, what was your previous job?
Your answer
How much were you earning monthly in your previous job?
Your answer
Do you have children and/or elderly who are dependent on you? If yes, how many? Please also provide their ages below. *
Your answer
If you need help paying utilities, please list the utilities and average monthly amounts needed below.
Your answer
If you need help paying your rent or mortgage payment, please list your monthly rent/mortgage payment below.
Your answer
Are you currently behind on your rent/mortgage payment?
If yes, how many months have you not paid rent/your mortgage?
Your answer
Are you at risk of being evicted?
Please use the space below to add any additional comments (optional).
Your answer
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