Shelter Assistance Request Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Did you apply for Emergency Assistance through your County?
Yes
No
Do you have a denial letter for Emergency Assistance from your County?
Yes
No
Do you have an eviction notice or late payment notice?
Yes
No
Have you or your family been affected by COVID-19?
Financially
Physically
Mentally
All of the above
I prefer not to answer this question
What is your monthly rent/mortgage amount?
When did you make your last payment?
Financial Release of Information - I hereby authorize CAER Food Shelf to seek/release information concerning me and/or my family which may be helpful in assessing my situation. This authorization given shall continue in effect until I revoke it in writing or the financial services provided to me are completed or terminated. This release includes Social Services
*
County Denial Letter
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Eviction Notice or Late Rent notice
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Rental Statement completed and signed by Landlord
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Mortgage Statement
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Submit
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