Emergency Assistance Fund Online Application

  * Required field
Student Information  
* First name:  
* Middle Initial:  
* Last name:  
* Phone number:  
* Street address:  
* City:  
* State:   * Zip
* Email:  
* HACC ID:  
HAWKMail email:  

Please select your location:

For what term are you requesting emergency assistance?
Please type the year:  
Please select what you will be using these funds for (check all that apply):

If you selected home catastrophe, auto repairs or other, please describe:


* Please enter the amount you are requesting:

* Please provide a written statement telling us about the emergency situation causing you to request help and why you need the funds:

Are you receiving Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) funds?

Vendor information  
* Description of request:  
* Confirm amount of request:  
* Vendor name:  
* Vendor street address:  
* Vendor city:  
* Vendor state:   Vendor zip:  
* Vendor phone:  
Vendor account number (if applicable):  

Additional documentation: Please email a copy of your unofficial HACC transcript, with documentation from the vendor, verifying the amount of the request to: haccscholarships@hacc.edu. Requests will not be considered without these two documents.

Please check that you have completed the following:

By utilizing my electronic signature, I certify that all of the information I have provided is true and correct to the best of my knowledge. I also understand that providing incomplete and/or inaccurate information will result in my request being denied.
* Student first and last name:                 * Date:   mm/dd/yyyy