Covid form - Hill Country Family Services

Hill County Family Services is committed to distributing the funds we receive from different donors in a fair way to our clients. To better serve you, we need your collaboration by being as honest as possible with your finances so that we can assess your immediate needs and help you in the best way possible.

Hill County Family Services se compromete a distribuir los fondos que recibimos de diferentes donantes de una manera justa para nuestros clientes. Para servirle mejor, necesitamos su colaboración siendo lo más honesto posible con sus finanzas para que podamos evaluar sus necesidades inmediatas y ayudarle de la mejor manera posible.

Have you been directly affected by COVID19? / ¿Ha sido directamente afectado por COVID19?*

Yes/ Si

If yes, please briefly explain how you have been directly affected./ Si su respuesta es sí, por favor explique brevemente cómo se ha visto afectado directamente.*

Did you or someone in your household lose their job because of the COVID19 virus? / ¿Usted o alguien en su hogar perdió su trabajo debido al virus COVID19?*

Yes / Si

N/A

How many people in your household are unemployed?/ ¿Cuantas personas en su hogar están desempleadas? *

How many people in your household are employed?/ ¿Cuántas personas en su hogar están empleadas?*

Did you or someone in your home lose your job for another reason?/ ¿Perdiste tu trabajo por otra razón?*

Yes / Si

N/A

If your answer is yes, please explain the reason for losing your job / Si su respuesta es sí, por favor explique la razón de perder su trabajo*

Have you applied for unemployment benefits? / ¿Ha solicitado beneficios de desempleo?*

Yes/ Si

If no, why have you not applied? /¿Si responde no, por favor díganos por qué no ha solicitado beneficios?*

Name/Nombre

First

Last

Date/Fecha

Phone/teléfono

First and Last Name*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone

Email*

Are you part of a group or organization that is volunteering with HCFS?

Yes

If Yes, what is the name of the group?

Is this for Court Directed Community Service?

Yes

First and Last Name*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone

Email*

Are you part of a group or organization that is volunteering with HCFS?

Yes

If Yes, what is the name of the group?

Is this for Court Directed Community Service?

Yes

First and Last Name*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone

Email*

Are you part of a group or organization that is volunteering with HCFS?

Yes

If Yes, what is the name of the group?

Is this for Court Directed Community Service?

Yes

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