Restaurants Care
California WildfiresGrant Application – October 2017

Restaurants Care, an emergency assistance fund for restaurant workers, has dedicated special funds to support restaurant workers affected by the October 2017 California wild fires.Funds are limited and grant amounts range from $250-$1,000 per individual.

Expenses we cover: Expenses we DO NOT cover:

•Temporary lodging related to displacement•Medical expenses or medical insurance premiums

•Food, clothing, supplies related to displacement•Insurance

•Food, clothing, supplies related to temporary •Loan payments
unemployment

Applicant Name: ______Date:______

Mailing address: ______

City, State, Zip: ______

Phone: ______Alt. Phone: ______

Email: ______Best way and time to reach applicant? ______

Gender (optional, for reporting purposes only): Female • Male • Non-Binary • Prefer not to answer

Number of Dependents: ______

Race (optional, for reporting purposes only):American Indian/Native American • Asian • Black/African American • Hispanic/Latino • White/Caucasian • Pacific Islander • Other • Prefer not to answer

Restaurant Name: ______

Work address: ______

Restaurant Phone Number: ______

ManagerName:______

Manager Email:______Cell#:______

Tell us about your restaurant (circle one): Quick Service•Fast Casual•Upscale Casual•Fine Dining

•Other (coffee shop/cafeteria/deli)

Tell us about your position (circle one): FOH • BOH

Job title: ______

Description of how you were impacted by the October 2017 wild fires (use another page if needed):

______

Please state how a grant help you:

______

Financial Worksheet

  • Please provide estimated monthly household income: $______
  • Please itemize the estimated monthly expenses:
  • Rent/mortgage $ ______
  • Transportation / Auto Insurance $ ______
  • Phone $ ______
  • Electricity $ ______
  • Gas / Water $ ______
  • Groceries $ ______
  • Personal Medical Insurance Premiums $ ______
  • Child Care $ ______
  • Other ______$ ______
  • Total Expenses$ ______
  • Will insurance cover any of the cost of the loss? (circle all that apply)
  • Auto
  • Home / Renters
  • Health/Medical
  • Life
  • If so, how much of the cost of the loss is covered by insurance? ______
  • Is the applicant receiving any other assistance? Y or N
  • If yes, describe: ______
  • Please provide the amount requested: ______

Required Items:

  1. Completed Application
  2. Statement of need and explanation of crisis (submitted by applicant or on their behalf). No more than one page in length. Must include information about how they were impacted by the wild fires.
  3. Completed Financial Worksheet

Submitted copies of all that apply:

___ Rent or mortgage bill or statement
___ Receipts for temporary lodging

___ Written letter from restaurant manager or owner stating that the business is temporarily closed

___ Current bank statement

Icertify that the information contained in this application is true, correct and complete. By signing the certification below, I authorize CRAF to request additional information as deemed necessary in the process of reviewing my request. I understand that this authorization is voluntary and may be revoked at any time by giving written notice of my revocation to the organization contact listed in this application.

Manager Signature: ______

Applicant Signature: ______

When complete, please return to: (scan and email). Or MAIL to: CRAF, 621 Capitol Mall, Ste. 2000. Sacramento, CA 95814 Or Fax: 916.431.2763.