New Haven County Covid-19 Hospitality Assistance Request Form
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Name *
What are your pronouns? *
Email? *
Phone Number? *
Date of Birth? *
Most recent place of employment? *
Are you an employee or employer (filling out for an employee)? *
Were you laid off? *
Were your hours cut? *
How much monetary assistance are you requesting today? *
Do you have a Venmo or Paypal account? If not choose other and explain below. *
Please explain *
What is your Venmo or PayPal handle? (If you don't have one please indicate N/A) *
Tell me a bit more about your current situation? *
How would you categorize your emergency? (if multiple, choose other and describe) *
Please describe... *
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