REQUEST FORM

"Thank you for contacting PATH Foundation. Please complete the form below. Submission of this form does not guarantee assistance. A PATH representative will review your request and contact you regarding available resources and eligibility."

Fields:

• Date and time of form (Month/Day/Year/Time)

• First name*

• Last name*

• Email

• Address*

• Phone

• Birthday (Month/Day/Year)

• Is this an emergency? Yes/No

• Do you currently have reliable transportation? Yes/No

• What language do you prefer to communicate in? English / French / Spanish / Arabic / Somali / Other

• Current Housing Status: Renting / Own Home / Staying with Family/Friends / Shelter / Hotel/Motel / Unsheltered/Homeless / Other

• Household Information

• Number of Adults

• Number of Children

• Employment Status: Employed Full-Time / Employed Part-Time / Self-Employed / Unemployed / Retired / Student / Other

• Please describe your current situation and how PATH Foundation may assist you (textbox)

• What type of assistance are you seeking today? (Check all that apply): Food Assistance / Housing Assistance / Temporary Lodging / Utility Assistance / Transportation Assistance / Immigration Referral / Counseling & Emotional Support / Resource Navigation / Repatriation Planning / Reintegration Support / Other

• Do you have food available for the next 72 hours? Yes/No

• Do you have an eviction notice? Yes/No

• Court date?

• Amount owed?*

• Food Needs: Yes/No

• House Size

• Dietary restrictions?

• Immigration Impact

• Would you like a referral to an immigration attorney or legal service provider? No/Yes

• Explain Briefly*

• Monthly Household Income*

• Amount of Rent Owed

• Best Time to Contact You

• Emergency Contact Name

• Emergency Contact Phone Number

• How did you hear about PATH Foundation? 211 / Friend/Family / Church / Social Media / Website / Community Organization / Other

• If you were referred by 211, please provide your referral number (if available)

• File upload/Document Upload — [+ Upload File]

• Single choice: I authorize PATH Foundation to contact me by phone, email, text message, or mail regarding my request for assistance.

• Signature

• Checkbox: I certify that the information provided is true and accurate.*

• Checkbox: I understand that submission does not guarantee assistance.*

"PATH Foundation reviews all requests individually. Submission of this application does not guarantee financial assistance, housing support, food assistance, transportation assistance, or any other service. Assistance is subject to eligibility requirements."

• Check (radio option, unclear context)

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​Checkbox: "I understand that submitting this request does not guarantee assistance and that any assistance provided by PATH Foundation is subject to available funding, program eligibility, and approval criteria."

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