STOP! PLEASE READ INSTRUCTIONS BELOW.

***INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND RECIPIENTS WILL BE REQUIRED TO RE-APPLY.***

***You will be notified only if/when your application is complete.***

INSTRUCTIONS (ALL ARE REQUIRED):

1. FILL OUT the ICNA Relief Financial Application below.

2. UPLOAD # 1: Copy of Photo ID (Passport, Drivers License, or Governmental ID) with ID # on Application.

3. UPLOAD # 2: Proof of Income (Last 2 Pay Stubs) or Unemployment Acceptance or Rejection Letter. Must show weekly or monthly pay rate.

4. ENTER Social Security Number on Application.

5. UPLOAD # 3: Outstanding Bill (Reason for Assistance) - If rent, you must include an official bill/invoice from your Landlord. Bills must clearly show the arrears amount and date.

6. FILL OUT the ICNA Relief Client Needs Assessment below. Link is ALSO in the email sent to you.

CLIENT NEEDS ASSESSMENT LINK: https://forms.gle/1UZg2LEmKJxG1Gtb6

Please properly label all documents and attach them to this email thread (reply all). Once all required documents are received, your application will be considered pending. After reviewing the documents, we will contact you directly if we have any further questions. Please note, the program is based on limited funding and may take 3-4 business weeks to be processed. If approved, we will be sending the funds via check only and cannot send funds through any eCommerce platform.

Name*

First Name Last Name

Date of Birth*

Month Day Year

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number*

Area Code Phone Number

Email*

example@example.com; If no email, please enter N/A.

SS#*

If you do not have a SSN, please enter N/A.

ID #

Enter ID, Passport or License # here.

Household*

Single Parent Female Single Parent Male Two Parent Single Person

Head of Houshold?*

Yes No

How many people in your household?*

What is your Housing Type*

Renter Owner

Are you Homeless?*

Yes No

If yes,

With Roof Without Roof

Upload: 1. ID 2. Proof of Income 3.Outstanding Bills. See ABOVE for details.*

Browse Files

Please make sure ALL 3 documents are property labeled and uploaded. If this section is incomplete, your application will NOT be processed.

I affirm that the information in this for is true and accurate according to my knowledge.

Applicant Signature*

Date*

Day Month Year

ICNA Relief Financial Application

Personal Information

Signatures