COVID-19 Assistance Request Form

If you were impacted by COVID-19 and need assistance, please complete the form below:

Note: Please only submit one application. Duplicate applications will not be considered.

Information for landlords and property owners

Important Information for Applicants

Eligibility Requirements:

Eligibility:

We are prioritizing help for individuals and families who have lost income as a direct impact of COVID: through job loss, wage loss, furlough, illness, quarantine, lack of childcare or other related incidents. You must belong to one of these groups:

Single-headed households with children
Families with 5 or more minor children
Immigrants/Refugees
Seniors (age 60+)
Disabled

Documentation Requirements:

Documentation Required:

Copy of your photo ID (driver’s license OR other official picture ID)
For rental assistance (any one of these): lease AND vacate/eviction notice, OR rental agreement document
For utilities assistance (any one of these): utility disconnect notice OR late payment notice
Proof of unemployment (any one of these): copy of Workforce Solutions appointment/application, letter stating you have lost unemployment, pay stub, letter of employment loss for informal workforce, OR declaration of lost income

For additional additional resources and information please visit Catholic Charities Coronavirus Information Page.

1 UPDATED COVID Assistance Form

COVID-19 Assistance Request Form

Date

Full Name: *

Date of Birth: *

Gender: *

Male

Female

Marital status: *

Married

Single

Primary language: *

English

Spanish

Other

Please list other language:

Are you a veteran? *

Yes

Race: *

Native American

Asian

Native Hawaiian or Other Pacific Islander

White

Black or African-American

Undetermined

Ethnicity: *

Hispanic or Latino

NOT Hispanic or Latino

Number of Adults in Household: *

Number of children under age 12 in household: *

Number of children between ages 12-18 in household: *

Total Number in Household: *

Has someone in your household been diagnosed with a disability? *

Yes

Total Household Income (Monthly): *

Please enter a number. If someone’s monthly income was $600.00, they would enter 600.

Household Income: *

No Income

Self-employed

Government Benefits

Hourly Employee

Salaried

Eligible for COVID unemployment/government stimulus? (NOTE: Your answer to this question will not impact your ability to receive assistance from Catholic Charities. See additional information from IRS.gov and the Texas Workforce Commission.) *

Yes

Phone: *

Second Phone Number:

Address *

Address

City

State/Province

Zip/Postal

Country

What kind of job have you most recently held? *

Housing status: *

Rent

Own

Estimated monthly housing payment: *

Please enter a number. If someone’s typical monthly housing payment was $600.00, they would enter 600.
Note: even if this was not paid in full last month, enter what this payment would usually be.

Were you able to make your monthly housing payment in full last month? *

Yes

Financial Impact

How were you impacted by the COVID-19 crisis? *

Job loss

Loss of job hours or wages

Unable to work due to childcare

Unable to work due to illness or quarantine

Unable to work due to caring for someone who is ill

Other (please specify):

Please describe:

Assistance Requested

Check all that apply: *

Rent

Food

Utilities

Mortgage

Counseling

Employment Assistance

Medication

Immigration Legal Services

Baby Items

Other (please describe):

Apartment name or name of landlord:

Briefly help us understand your situation:

Additional Questions

Your answer to these questions will not affect your access to financial assistance.

In the past month, how much did your household spend on housing, not including utilities? This includes rent/mortgage costs, necessary maintenance, and home owner/renter insurance. *

Please enter a number. If someone spent $600.00 housing, they would enter 600.
Note: utility costs are covered in the next question.

In the past month, how much did your household spend on utilities? This includes things like water, sewer, electricity, gas, and heating. *

Please enter a number. If someone spent $600.00 utilities, they would enter 600.
Note: even if these costs are included in your monthly housing payments, enter what you think your expense for utilities was.

In the past month, how much did your household spend on food? This includes things like groceries, eating outside of the home/take-out, and beverages. *

Please enter a number. If someone spent $600.00 food, they would enter 600.

In the past month, how much has your household spent on things outside of the bills and expenses listed previously (housing, utilities, and food)? This might include things like transportation costs, childcare, medical expenses, education or loan payments, and other personal expenses. *

Please enter a number. If someone spent $600.00 food, they would enter 600.

Getting enough food can be a problem sometimes. How confident are you that your household will be able to afford the kinds of food you need for the next four weeks? *

Not at all confident

Somewhat confident

Moderately confident

Very confident

(Select only one answer.)

Consent to Participate in Study

Catholic Charities Galveston Houston (CCGH) is doing research about emergency financial assistance. You are invited to participate!

This research is being done with the Wilson Sheehan Lab for Economic Opportunities (LEO) at the University of Notre Dame. You were invited because you met the requirements to apply for assistance. We are doing this research to find out how our assistance can best help people and families like yours.

If you agree to participate, the researchers will collect and track information about you. This includes linking to records that are already collected about you from government and private agencies. We will only share the bare minimum amount of personal information needed for these agencies to match their records. By receiving that information, agencies will know that you are a part of this study, and have applied for assistance at Catholic Charities. They will not share information about you and will only use it for their matching process. The researchers might contact you to do a follow-up survey.

The research team will do its best to keep your records safe. They can’t guarantee confidentiality, but the risks to your information are small. Your information will be stored in a secure way. Encryption and password-protection will add security whenever your information is sent to researchers or stored at Notre Dame.

You do not have to be in this study if you do not want to. Your choice does not affect your chance to receive assistance. If you agree but later change your mind, you can drop out at any time and no further information will be sent to LEO. If you do change your mind, LEO will keep any information they had collected about you in the study up to that point unless you ask otherwise. There are no penalties if you do not want to participate.

If you have any questions about CCGH services, you can contact (713) 874-6607. If you have questions about this project or if you have a research problem, you can contact the researcher, Patrick Turner, at (574) 631-5093 or pturner4@nd.edu. If you have questions about your rights as a research participant, you can contact the Notre Dame Office of Research Compliance at (574)-631-7432 or compliance@nd.edu. You will get a copy of this form for your records.

Do you consent to partake in this study? By clicking “yes” below you are indicating that you are at least 18 years old, that you understand the procedures described above, and that your questions have been answered to your satisfaction. *

Yes

Do you agree to be contacted after your study participation for additional information? *

Yes

By checking this box and typing my name below, I am electronically signing this consent form. *

(Please check here.)

Typed name:

Date

Acknowledgement and Consent for Services

I, the undersigned, hereby authorize the release of information to Catholic Charities of the Archdiocese of Galveston-Houston for the purpose of determining program eligibility and monitoring program compliance. (The disclosures made are limited to the information listed here: Houston Food Bank; United Way.) By selecting "yes, I agree" below, I am acknowledging that I have read and understood Catholic Charities' eligibility forms prior to submitting this application for assistance. (Read and review the consent information: ENGLISH | SPANISH). *

Yes, I agree.

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