COVID-19 Community Response Fund Application

1

Name of Organization

Name of Organization

2

CRA #

CRA #

3

Your name

Your name

4

Your telephone number

Your telephone numberext.

5

Your email address

Your email address

6

How has COVID-19 impacted your programs and/or services?

How has COVID-19 impacted your programs and/or services?

7

What is your organization's current, immediate need, including the dollar amount you are requesting?

What is your organization's current, immediate need, including the dollar amount you are requesting?

8

Are you receiving any other funding to help support this immediate need?

Are you receiving any other funding to help support this immediate need?

Yes

No

9

If you answered "Yes", what funding have you received?

If you answered "Yes", what funding have you received?

10

Please describe the program and your plan for delivery of service.

Please describe the program and your plan for delivery of service.

11

How many individuals need access to this service/program?

How many individuals need access to this service/program?

12

What is the demographic you will be serving?

What is the demographic you will be serving?

13

If you qualify for immediate financial assistance, do you agree to track and report back to United Way with the number of individuals and demographic that benefited from this financial assistance?

If you qualify for immediate financial assistance, do you agree to track and report back to United Way with the number of individuals and demographic that benefited from this financial assistance?

Yes

No

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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