IFSI Assistance Request Form

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Please contact IFSI at info@ifsi-usa.org or (857) 251-9806 for more information.

Email *

Cash Assistance

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Option 1

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6173770453Phone number (Nimewo telefòn) *

2 Household size: how many people live with you at your home? (Konbyen moun k ap viv avèk ou lakay ou ?) *

What would you like help with today? (Ak kisa ou bezwen èd jodya ?) *

Food - to purchase food for me and my family (Manje - pou achte manje pou tèt mwen ak fanmi m)

Bills - to pay for bills - please list in the question below (Fakti - peye pou fakti / bil - souple dekri ki bil nan kesyon pi ba a)

Baby sitting (Gadri timoun)

Taking care of a sick person (Pran swen yon moun ki malad)

Housing (Lòjman / kay)

Other:

Phone and Electricity.If you need help with bills, please list which bills you need help paying. NOTE: this question is OPTIONAL. (Si w bezwen èd pou peye fakti / bil, souple ekri ki bil ou bezwen èd avèk. NB - kesyon sa a pa obligatwa pou reponn).

If you answered OTHER above, please describe. NOTE: this question is OPTIONAL. (Si w te reponn LÒT/OTHER pi wo a, souple dekri ki bezwen ou genyen. NB - kesyon sa a pa obligatwa pou reponn).

Would you like to speak with someone about how the crisis has affected your mental or pscyhological health? (Èske w ta renmen pale ak yon moun konsènan kòman kriz sa a ap afekte eta sante mantal oswa sikolojik ou ?) *

Yes (Wi)

No (Non)

What is your preferred language? (Ki lang ou pale pi byen ?) *

English (angle)

Haitian Creole (kreyòl ayisyen)

French (franse)

Spanish (panyòl)

Portuguese (pòtige)

Cape Verdean Creole (kreyòl kapvèdyen)

Other:

What is the best way to contact you? (Ki pi bon fason pou n kontakte w ?) *

Phone (telefòn)