Toggle navigation
CIIERF
Login
Comunidades de Imperial Immigrant Economic Relief Fund
Application Questionnaire
PART I. FINANCIAL NEED
How have you been most affected by COVID-19? Select all that apply.
Lost job
Lost wages
Furloughed
Uncertain about returning to job
Have health issues
Anxiety/Stress
Loss of Childcare/School
Cannot seek employment due to childcare responsibilities
What is your greatest financial need right now? Select Top Three (3).
Rent
Utilities
Food
Medication/Healthcare
Childcare
Remittances
Other
Have you applied for other services/resources? Select all that apply.
Unemployment
Food Stamps
Rent/Mortgage Assistance
Other
PART II. APPLICANT INFORMATION
First Name
Middle Name
Last Name
Street Address
City
County
Zipcode
State
Country
Mobile Phone
Email
What is your age?
What is your gender?
-- Select Value --
Female
Male
Nonbinary
Transgender
Decline to State
Other
Other Gender
What is your race/ethnicity?
-- Select Value --
Latino/Latina
Black
White
Asian/Pacific Islander
Indigenous
Multi-Racial
PART III. HOUSEHOLD
How many people depend on your income, including yourself?
How many household members are 18 and over?
How many household members are under 18?
Which languages are spoken at home?
-- Select Value --
English
Spanish
Other
Other Languages
In which COUNTRY were you born?
-- Select Value --
United States
Mexico
Other
Other Country Born
PART IV. EMPLOYMENT
Year
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Months
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
What is your primary occupation?
-- Select Value --
Childcare
Domestic Work
Farm Work (Agriculture)
Food Processing
Healthcare
Hospitality
Janitorial
Gardening/Landscaping
Personal Care
Restaurant
Retail
Transportation
Other
Other Occupation
PART IV. OTHER
Were you referred to this program?
By which organization(s)?
Apply