COVID-19 Emergency Financial Assistance Application Please review the guidelines for this program before submitting. Please enable JavaScript in your browser to complete this form.Applicant Name (Head of Household) *FirstLastEmail *Mailing Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysical Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAssistance Requested (You can only choose one.) *RentMortgageElectricityPropane/Natural GasGarbageWater/SewerNoneNOTE: CCST will make a payment on a single bill with a maximum payment of $500.How have you been impacted by COVID-19? *Stay at home orderShelter in placeSelf-quarantineWork hours lostIncome lossOtherNoneOther Impact Description *Please list all household members at this address. *(One member per line. Press "Enter" between each member's name.)Comment or MessageFile UploadsUpload Scan/Photo of your Tribal ID nowScan/Photo of your Tribal ID Click or drag a file to this area to upload. Upload Supporting DocumentUpload Scan/Photo of your Mortgage Statement, Rental Agreement, Utility Bill, etc. nowScan/Photo of Mortgage Statement, Rental Agreement, Utility Bill, etc. Click or drag a file to this area to upload. NOTE: CCST will make a payment on a single bill with a maximum payment of $500.CommentSubmit
