EAA Intake Form

EAA Southern California Wildfire Member Assistance Intake Form
We understand that the recent wildfires have had a devastating impact on many in our community, and our hearts go out to those who have suffered losses. In response, EAA Union has established an Ad-Hoc Wildfire Relief Committee dedicated to providing financial assistance and resources to any EAA member who has experienced loss, displacement, or impacted in other ways due to the fires, we encourage you to apply for assistance.

View the EAA Southern California Wildfire Member Assistance Policy
EAA Member Details:
Full Name*

First NameLast Name
Employee ID*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide current address (as of Jan. 6, 2025)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
Have you been impacted by the recent Wildfires*
Household Status*
Family Status*
Current Employment Status*
How many people live in your home*
How many families live in the house*
How many children are ages 0 - 17
How many adults are ages 18 - 54
How many adults are seniors age 55+
Please describe why you are requesting assistance? (Example - home destroyed, no access to home, clean up cost, hotel cost)*
Rank in order type of assistance.
If Utility Assistance is needed, please fill out below.
Utility name, and total amount owed.
If requesting Rental Assistance, please fill out below.
Monthly rent amount.
How much rent can you cover?
Landlord's Address
Street, City, State, Zip Code
Landlord's Phone Number
.
Landlord's e-mail address
.
If requesting Mortgage assistance, please fill out the fields below.
Monthly mortgage amount
Name of mortgage lender
How much of your mortgage can you cover?
Other Type of Assistance

If you are seeking assistance for something other than food assistance, utility assistance, rent assistance or mortgage assistance, please fill out the following field.
Please let us know what additional assistance you are requesting and how this will support your current needs?
Supportive Documents

Please upload the supportive documents requested below as PDF's. Applications will be considered incomplete if documents are not uploaded.

For all applicants:

- LA City Pay Stub

For those requesting utilities assistance:

- Utility Bill

For those requesting rent assistance:

- Rental Agreement

For those requesting Mortgage assistance:

- Mortgage Statement
File Upload of Supportive Documents

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A copy of your responses will be emailed to the e-mail address you provided.
Should be Empty:

EAA Southern California Wildfire Member Assistance Intake Form

EAA Member Details: