Assistance Request Form
If you have lost your home in the devastating LA fires and will be renting a home, and if you need support with home furnishings; please complete this form. We will get back to you as soon as possible to offer any and all assistance we can. 
Sign in to Google to save your progress. Learn more
Email *
Did you lose your home in the LA area fires? *
Did you own or rent the house that you lost?
 *
Have you secured a new rental home? *
Are you requesting assistance to furnish the entire home of your new space? *
What is the address of the home you lost? *
Can you provide a utility bill or the likes for the property you lost? *
Did you have insurance on the home or apartment you lost?  *
If you had insurance, who was your insurer (enter N/A if you did not have insurance)? *
If you did not have insurance, is FEMA providing you support (enter N/A if you have insurance)? *
If you have a FEMA number, please enter your it below. If you do not have a FEMA number, please enter "N/A" *
What is the address for your new space? *
What city is your new space in? *
What state is your new space in? *
What is the zip code of your new space? *
How much monthly rent will you be paying for your rental unit?
 *
What is your occupation? *
Has your income been affected by the fire? *
If your income has been affected by the fire, please explain what the impact has been (enter N/A if not affected): *
Are you currently employed? *
If you are currently employed, what is the name of your employer (if you are currently unemployed enter N/A)?
 *
How long have you been at your current job (if currently unemployed, enter N/A)? *
Is your employment stable?  *
How many hours per week do you work? *
Are you in school? *
If you are in school,  what is the name of your school (enter N/A if not in currently in school)? *
If you are in school, how many hours per week do you go to school? *
What is your current household income level? *
What is your Total Gross Documented Income per Month? *
Do you have a crowdfunding campaign (ex. GoFundMe)? *
If you have a crowdfunding campaign, please provide the link (enter N/A if you do not have a crowdfunding campaign)? *
Is your new housing empty and in need of full furnishings or do you need specific items for your home? Please provide details below.
 *
What is your first name? *
What is your last name? *
What is your best contact phone number? *
Please confirm your email address? *
What is your age range? *
What is your birthday? *
MM
/
DD
/
YYYY
Have you ever been a part of the foster care system? *
Before we can dig in, please carefully read and accept our terms below by entering in your full name

TERMS AND CONDITIONS
By completing this application you understand and accept that the furniture and housewares you are requesting have been received as donations to A Sense of Home. Therefore, the items you will receive have mostly been previously used. While we do our best to provide you items with minimal wear and damage, you understand that they are not in brand new condition. Once the items are placed in your home, they belong to you and A Sense of Home does not make repairs or replacements of the items. Items received by Home Bank may not be sold. We can consider recipient donating items to A Sense of Home should they no longer need them in the future. 
 *
How many bedrooms does your new rental have? *
How many bathrooms does your new rental have? *
Does the unit have an outdoor space? *
Does the unit come with a refrigerator?  *
Does the unit come with a stove?  *
What other appliances do you have? *
How many total children are in your household? *
How many total Seniors (62+) are in your household? *
Who else will be living with you? This does not deter you from getting services, we just need to know for design purposes. *
How many total adults live in your household? *
What are your preferred pronouns? *
Do you identify as LGBTQ (This information is collected for demographic analysis only and will be kept confidential)? *
What is your gender identity (This information is collected for demographic analysis only and will be kept confidential)?

 *
What is your ethnicity (This information is collected for demographic analysis only and will be kept confidential)?

 *
What is your marital status? *
What are you favorite colors for the living room and bedrooms? *
What do you do in your free time? What would you do if you had more free time? *
When you close your eyes and imagine yourself in a soothing relaxing place — what do you see? *
Do you have pets? If yes, enter details in "Other" *
What kind of space design inspires you? *
How do you envision your space? (Ex. Calm, peaceful, colorful, soothing etc )  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of A Sense of Home.

Does this form look suspicious? Report

Google Forms