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PBEP Mutual Aid Fund Request Form
First name(s)
*
Last name(s)
*
Email address
*
Phone number
*
Do you identify as Black or are you responsible for Black dependents?
*
Do you identify as Black or are you responsible for Black dependents?
A
Yes
B
No
Are you financially responsible for yourself and/or your household?
*
Are you financially responsible for yourself and/or your household?
A
Yes
B
No
Do you live in Pasadena or Altadena?
*
Do you live in Pasadena or Altadena?
A
Yes
B
No
What is your zip code?
*
Please tick the box below to confirm that this financial hardship means you cannot meet your basic needs, and you do not have the independent financial means to weather this hardship.
*
Please tick the box below to confirm that this financial hardship means you cannot meet your basic needs, and you do not have the independent financial means to weather this hardship.
I confirm.
Which type of assistance are you requesting? Please choose one category.
*
Have you received funds from PBEP before?
*
Have you received funds from PBEP before?
A
Yes
B
No
Have you been directly impacted by Eaton Fire?
*
Have you been directly impacted by Eaton Fire?
A
Yes
B
No
This program is intended to support individuals and families experiencing financial hardship. Tell us, briefly, about the cause of your hardship, what bills you need to pay, and about the difficulty of your current financial situation.
*
Minimum 250 characters.
Would you prefer a virtual gift card or a physical one?
*
If you select physical, you will be asked to provide your mailing address to our gift card partner, a for-profit company.
Would you prefer a virtual gift card or a physical one?
A
Physical
B
Virtual
Additional comments/feedback.
*
I attest that all information included here is true and accurate to the best of my knowledge.
*
Signature
Submit
