Community Assistance Fund » Gold Hill Relief Fund Appliction

Gold Hill Relief Fund Appliction

Posted on: September 22nd, 2014

Gold Hill Town Meeting Community Relief Fund Application Effective 6/2014

Please use back of form or additional sheets as needed.

 


Mail completed form to:

We need to know the best way to contact you: phone, email, text, etc.
Gold Hill Town Meeting, Inc.

Attn: CRF

1011 Main Street – Gold Hill

Boulder CO 80302

 

 

 

 

 

Criteria: (1) Applicants must be a resident of Gold Hill Town Meeting, Inc., defined area, (2) Application signed and dated and (3) meet criteria A or B below:

A. Disaster, such as flood, fire, etc. Maximum $1000 per event, per household – committee approval needed

B. Family emergency such as lost job, hospitalization, car accident, etc. Maximum $250 per household annually– committee approval needed

 


 

Name _____________________________________________________________________________________________

 

Home Address ___________________________________________________________________________________________

 

Mailing Address if different: ____________________________________________________________________________

 

Phone/Contact Information: ___________________________________________________________________________

 

Please explain your circumstances and what assistance is requested.  Specifically itemize/estimate amount to be used to replace losses (such as income, house repair, clothing, food)   __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Please list other organizations from which you have received/or plan to receive financial help:

 

__________________________________________________________________________________________________________

 

Signature ________________________________________________________________Date___________________________

 

GHTM use only:

 

Date Received: ___________________                          Applicant number:___________________________

 

Applicant Qualifies for Criteria A   or   B  (circle one) Amount disbursed$__________________

 

Approved by: 1. _________________________2__________________________3. _____________________________