Application for Assistance

If your family, or you know of a family that needs our assistance, in the state of Idaho, then please fill out the application below.

Completion of this application is in NO WAY a guarantee of assistance. (Police report is required before any assistance will be paid.)

You will be contacted upon approval/disapproval


Person Completing Form

* Required






Rider 1 Information












Rider 2 Information (If Applicable)



Check this box if address same as rider 1.








Family Contact Information

Check this box if information same as person completing form.