Chaffee County Emergency Assistance Request Form
***AT THIS TIME, IF YOU DO NOT HAVE DEPENDENT CHILDREN IN YOUR HOME, WE ARE NOT ACCEPTING APPLICATIONS FOR ASSISTANCE.  WE APOLOGIZE FOR THE INCONVENIENCE.

If you have already received financial assistance from the Chaffee County Community Foundation, please STOP and DO NOT complete this form.  Instead, please submit a re-application form at: https://www.chaffeecommunity.org/erf-reapplication.

If you have not yet applied for assistance, please use this form to request assistance if your household is experiencing hardship due to the impact of COVID-19.  Examples of assistance needed could include, but are not limited to: rental/mortgage assistance, utility assistance, emergency food assistance household supplies and transportation assistance.  Please note that you must be a resident of Chaffee County to be considered for eligibility.  We will do our best to contact you within 2 business days.  This assistance request form will be reviewed by Chaffee County Human Serivces and by the Chaffee County Community Foundation.  


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What is your full name? *
What is your phone number? *
What is your email address?
What is your physical address? *
What is your mailing address? *
How many people are in your household? *
Are there any children under the age of 18 in your household? *
Are you and/or members of your household lawfully present in the United States?  Please note that if your answer is "No", it does not mean that you will not be eligible for assistance *
What is the CURRENT income for your household?  If you have been laid-off and are waiting to return to work or have applied for unemployment benefits but have not begun receiving them yet, you can say that your income is $0.00 at this time *
What type of assistance do you need at this time? *
Required
What is the amount that you are requesting? *
Have you applied for Unemployment Insurance Benefits? *
Have you received a disconnect notice, an eviction notice or are you in immediate jeopardy of losing housing or basic utilities? *
Any additional information can be added here. Please also include a description of your current need *
Do you have verification of your residency in Chaffee County?  ***This could include a piece of mail, a current ID, paystub, or anything else that shows your current address.  If so, you can email it to chaffeebenefits@state.co.us.  Please put in the subject line: CHAFFEE COUNTY EMERGENCY ASSISTANCE.  You can take a screenshot or a photo of the residency verification.   *
By checking this box, I certify that the information given is true and accurate.  I also authorize Chaffee County Human Services and Chaffee County Community Foundation to review and discuss my case. PLEASE CHECK BOTH BOXES. *
Required
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