Resilient Randolph - Covid-19 Response Fund
PLEASE READ CAREFULLY. If you are a Randolph resident in need of financial help due to Covid-19, please fill this form out to the best of your abilities. Filling out this form does not automatically make you eligible for funds, funds will be distributed and prioritized based on need. We will reply as soon as we are able however please keep in mind that we are receiving hundreds of applications. Please watch for an email from randolphresiliencycommittee@gmail.com in case we have questions about your application. IF YOU have previously applied and have not me the household cap of $2000 you may email us to update your original application, please do not submit a new one.
Preferred language should we need to contact you: *
First Name *
Last Name *
Address *
Phone Number(s) *
Email Address *
Are you a Randolph resident? *
Your Date of Birth *
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Ethnicity: *
Are you experiencing financial hardship due to the Covid-19 pandemic or how has your employment status changed since the onset of COVID-19? *
Required
If you answered that you were previously working or "other" above, please provide more information here including previous employer address and name if applicable.
Current Wages (salary, hourly rate, or weekly pay): *
How many people live in your household - names and ages *
What are the financial hardships you are experiencing related to the COVID-19 emergency (please be specific about minimum amounts owed to maintain housing or utilities and needs)? If you qualify for assistance, we will send payment on your behalf directly to who you owe (except for basic needs). *
Funds may be used flexibly to support individuals and families with financial hardship or disruption directly related to this crisis. Please indicate the area in which you MOST need assistance: *
Required
Depending on your selection from the previous question please list the name, address, loan number (if applicable) and contact information for your lender (mortgage help), landlord name, street address, and email address (rent help), utility company name, account #, and address (for utility help) in order for us to send a check on your behalf if you qualify for funding. Please select N/A if you are looking for help with basic needs (food, diapers, etc.): *
I attest that the above information is true, to the best of my knowledge. You may be asked to provide documentation as proof of your current financial status. *
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