COVID-19 [Personal] Relief Fund Application

First Name *

Last Name *

Home Street Address *

City + State + ZIP *

Phone Number *

Name and Relationship of other Adults in the household?

Names, ages, and relationship-to-you of Children in the household?

Type of help needed & Verification Information *

IF RENT / MORTGAGE: Please provide the name of your Landlord/Rental Company, their name, address, phone number, and the amount due.

IF UTILITIES: Please provide the name of your utility company, name the service is under, account number, and amount due.

Were you working in Mohave County at the time of your job loss or wage reduction? *

If Yes - Name of Employer

Date of job loss or wage reduction *

Hourly Wage Prior to March 1, 2020 *

Do you have a job you will be returning to? *

No
Yes, current employer
Yes, new employer

By checking this box, I certify the accuracy of the information provided in this application and formally request assistance. In addition, I give permission for River Cities United Way to share my information with applicable funding sources, utility providers, and landlords/mortgage companies for the purpose of processing my application and preventing duplication of service. *

I Agree

Submitting an application does not guarantee assistance. A phone/email interview will be conducted in further consideration of assistance. River Cities United Way and it's partners will assist to the best of their abilities. *

I Understand

Check each box below to show acknowledgement and understanding. *

I understand RCUW does not pay late fees. I will be responsible for these.
I understand RCUW does not pay "Disconnect" or "Reconnect Fees". I will be responsible for these.
I understand RCUW will only pay 1 month worth of my bill.
I understand there is no guarantee to the amount of assistance I will receive.
I understand the application process takes up to 2 weeks to approve.

Upload copy of bill you are requesting assistance with

Drop your files here or click here to upload You can upload up to 10 files.

Alternatively, you can take a photo of your bill (all pages) and email to Debi@RCUW.org

Please give us a brief explaination of how COVID-19 has put in this position. *

If I receive funding, I would be willing to participate in the following:

In-Person Video Testimonial
Telephone Recorded Testimonial

COVID-19 [Personal] Relief Fund Application

COVID-19 JOINT RESPONSE GRANTS

FUNDING PRIORITIES

ELIGIBILITY