Request help

Tell us what's happening

There's no fee to ask. A member of our staff will review your request and reach out to you directly. This takes about fifteen minutes.

Personal Information

First name *

Middle name optional

Last name *

Date of birth *

Home address *

Apartment / unit no. optional

City *

State *

ZIP *

Personal email *

Cell phone *

Home phone optional

People in your household, including yourself *

Are you a veteran? optional

Who lives with you, and their relationship to you *

Gender optional

Race / ethnicity optional

Do you have a disability? optional

We ask the three questions above only for our own reporting. Answering them has no effect on your request.

Where did you hear about us? optional

If other, please say where optional

Employment Information

If you are not currently working, enter your most recent employer, or write "None".

Employer or organization *

Any employer — company, agency, school, nonprofit, or self-employed.

Employment status *

Position or job title *

Work phone optional

Your direct line and extension, if you have one.

Work email optional

Employer address optional

Employer city optional

Employer state optional

Employer ZIP optional

Pay grade or level optional

Leave blank if your employer doesn't use grades or levels.

Emergency Information

What is the reason for your request? *

If you chose "Other", tell us briefly what it is optional

What expenses are you seeking help with? *

Rent or mortgage payments Home utilities Medical expenses not covered by insurance Funeral expenses Emergency travel or temporary lodging Other

Choose at least one.

Describe the circumstances that led you to ask for help *

Up to 2,000 characters.

Attach supporting documents optional

PDF, JPG, or PNG. Up to 6 files, 10 MB each. Helpful documents include a copy of the bill you need help with, proof of what happened (a report, a letter, a death certificate), a recent pay stub, and a photo ID.