Application for 2017

Community Disaster Response Fund for

Nevada County

Name: ________________________________________________________ Todays date: _____________

Name of fire that impacted you: ____________________________________________________________

Address where damage occurred, including zip code (note: only one application per household):
________________________________________________________________________________________

Current mailing address: __________________________________________________________________

Telephone: _________________________ E-mail (if any): _______________________________________

If you rent, name of landlord: _____________________________ Number: _________________________

Proof that this was your primary residence at the time of the fire is required.
This is the address you use on your federal tax return, your voter registration, your drivers license or other photo
identification, and your utility bills. Please provide a copy of any one of these documents with your application.

Briefly explain how you were impacted by the fire. Was your primary residence destroyed or significantly
damaged by the fire? Was your car destroyed? Did you have evacuation costs?

To what degree, if any, are you insured for any of your losses? (renters, homeowners, and/or car insurance)

Is there anything else you would like to tell us about your situation or circumstances?

Signature: __________________________________________ Date: __________________

Return completed application by email to | Chaplain Sam Barger

sbarger@gvpd.net | By mail or drop off to: 129 S. Auburn St. Grass Valley, CA. 95945
c/o Police Chaplains

DEADLINE TO APPLY: All applications must be received by November 30, 2017

PLEASE COMPLETE QUESTIONS ON REVERSE SIDE

 Please take a moment to complete this demographic information.
CDRF will use this data for administration purposes only; your answers will NOT affect your eligibility.
How many people are in your household? Adults: ______ Children: _______ Total in Household ______

(M=Male F=Female)
Marital

HEALTH INSURANCE?
Race

Latino (Yes or No)

EDUCATION

ARE YOU DISABLED?

AA= African American Status 0-8
W=White NM=Never

(Y=Yes N=No)
(Y=Yes N=No)
Relation to 9-12/non graduate

DO YOU HAVE
NA= Native American married

Birth Date
Head of A= Asian M=Married H.S. Grad/GED
Household Name 12+ some college

Gender
O=Other D= Divorced
Partner/ Last, First MR= Multi Race S= Separated 2 Year Grad.
Child/Etc. W= Widow 4 Year Grad.
Self

FAMILY TYPE HOUSING MILITARY/OTHER MARK ALL THAT APPLY W/ NAME

Single Person Own MILITARY/veteran
Two-Parent Household Buying Farmer
Single Parent Rent Seasonal farm worker
Adults- No Children Homeless No English
Temporarily Living with
Adults & Children friend/relative
Other: _______________ Other: _________________

Source(s) of Household Income and Benefits (please indicate how many members of your family receive each source)
No Income Public Assistance/General Assistance Farm/Other Migrant Ag Work
Veteran Benefits TANF SSI- (65 or older/disabled)
Unemployment Pension/Retirement Other: ______________________
Social Security Employment FT / PT ___________________________
CALWORKS Odd Jobs_____________________________ CRV-recycling

Total Annual Household Income, including all sources (please select one)
$0-$10,999 $11,000-$19,999 $20,000-$29,999 $30,000-$39,999
$40,000-$49,999 $50,000-$59,999 $60,000-$69,999 $70,000-$79,999
$80,000-$89,999 $90,000-$99,999 $100,000+

AGENCY USE ONLY: