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Emergency Assistance Fund Online Application

* Required field  
*Are you a credit or noncredit (Workforce Development) student?

 
*Which fund best fits your request?
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:

 
* In at least 75 words, please provide a written statement explaining why you are requesting help from the emergency assistance fund. (If your explanation is fewer than 75 words, your application will be rejected):
 
 


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 copy and paste your unofficial HACC transcript in a Word document.
  • Please provide your documentation from the vendor.
  • Please email 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