The Center for African American Health Empowering the Community to Live Well! EMERGENCY ASSISTANCE REQUEST ‘The Center for African American Health (CAA Health) is working to ensure that our community members who are most in need, receive immediate assistance to help minimize the impact of the COVID-19 public health crisis. CAA Health has implemented a financial assistance process to support eligible individuals during the COVID-19 public health crisis until funding is no longer available. To receive support, please complete the following questionnaire, describing how you have been directly impacted by the COVID crisis and briefly explaining how the requested funds will be used. Assistance will be provided in increments of $100-$500, depending on family size and purpose. Questionnaires will be reviewed and approved weekly. Requests received by 5:00pm each Friday will be considered for funding by Friday of the following week. Payments will be processed via Bill.com. Recipients will be able to choose payment via electronic deposit or check. Name: Mailing address: 1. Briefly describe how you and/or your immediate family have been impacted by the COVID-19 crisis. 2. What is your household size? 3. Are you currently employed? [" ]¥es [_]No 4. If not, have you been employed in the past 12 months? [_]¥es [_]No 5. How do you plan to use the funds? Check all that apply. Groceries Renvmortgage or utilities Essential needs (toiletries, cleaning supplies, underwear, socks) Medical assistance and/or supplies Other: oo0080 6. Would you like to receive additional information regarding CAA Health services and programs? Fyes [> ]No For additional support, please email TeAsia@caahealth.org. 3350 Hudson Street / Denver, CO 80207 / (303) 365-3428 / F: (303) 355-1807 / caahealth.org / #¥&