Fillable Disaster Relief Fund Application (California State University Channel Islands)

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Disaster Relief Fund Application (California State University Channel Islands)

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Ekho Your Heart
DISASTER RELIEF FUND APPLICATION
A special disaster relief fund has been established under the Ekho Your Heart Program to assist CSUCI students, staff, and faculty
recovering from disasters such as the 2017 Thomas Fire or 2018 Holiday Fire, as well as other disasters that may affect members
of the campus community. This fund has been established to help provide basic necessities to those with the greatest need.
APPLICATION PROCESS
1. Complete the Application Form with appropriate explanation and supporting documentation.
2. Print, sign and deliver to Human Resources, Lindero Hall, Room 1804.
OR Print, sign, scan and email to HRServices@csuci.edu or fax to 805-437-8491
WHO’S ELIGIBLE
Applicants must be current CSUCI student, staff, or faculty and be able to document a short-term financial hardship resulting from
a disaster such as the 2017 Thomas Fire or 2018 Holiday Fire. This fund is not intended to cover expenses otherwise covered by
an applicant’s insurance.
POTENTIAL AWARD AMOUNT
Awards will be granted on a case-by-case basis up to $1,000. Awards may be subject to income tax.
SELECTION
The Ekho Your Heart Disaster Relief Fund Committee will meet to review applications and recommend to the President those
selected to receive funding.
Funds are limited and will be awarded in the order in which applications are received. All information pertaining to this applica-
tion and subsequent award will be confidential to the extent allowed by law.
Questions may be directed to Human Resources at HRServices@csuci.edu, Lindero Hall 1804, or 805-437-8490.
Internal Use: Employee __ yes __ no Approved __ yes __ no Award Amount: ________
EKHO YOUR HEART DISASTER RELIEF FUND APPLICATION
Please check one and complete ALL information in fields below.
Student Faculty Staff
LAST Name _______________________________ FIRST Name ______________________________ Middle Initial _______
Student/Staff/Faculty ID Number __________________________
Current Mailing Address _________________________________________________________________________________
City ___________________________________________________________ State __________ Zip ___________________
Email _______________________________________________________ Telephone _______________________________
Amount Requested __________________________________________________
Please provide detailed answers to the questions below. Attach additional documentation if needed.
1. Please provide a short description of the disaster that affected you (e.g., December 2017 Thomas Fire):
2. In what way did the disaster affect you (check all that apply)?
P
rimary residence was destroyed or significantly damaged
Lost personal belongings
Incurred temporary expenses related to evacuation
Other
Please explain further in box below.
3. H
ow will these funds assist you in meeting your needs?
I, the undersigned, certify that the information provided on this application is true and that the amount requested under this
application is not covered by other insurance coverage.
A
pplication Signature ___________________________________________________________ Date _______________________
A
pplication Name (print) _____________________________________________________________________________________
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Disaster Relief Fund Application (California State University Channel Islands)

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Completed 20 July 2020

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