Assistance Submission Form

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Relief Fund

Eligibility & Application

Eligibility

People of color and/or individuals living in economically distressed communities who are:

Current residents of Winston-Salem/Forsyth County
Experiencing a loss of household income (unemployment, furloughed, or decreased work hours) due to COVID-19

Available financial and resource assistance: rent, mortgage, utilities, medication cost or copay, food, transportation, and groceries

Max: Up to $300 per household- Contact traditional emergency assistance programs prior to completing the application below (Crisis Control, The Salvation Army, Sunnyside Ministries, Forsyth County DSS Crisis Intervention Program)

*Unmet needs will be supplemented with additional resources within Winston-Salem/Forsyth County*

Required Documentation

Picture ID
Proof of Crisis (late notice, eviction, disconnection notice, medication cost or copay)
Proof of Income (unemployment application submission, food stamp application submission, paystubs, letter from employer)

Application for Assistance

All fields must be completed before the form can submitted. We will contact you within 24 hour to provide you with the status of your application.

First Name

Last Name

Email Address

Address

Phone Number

Has any member of your household experienced a loss of inome due to the COVID-19 crisis?

Yes

If yes, provide a brief description of income loss and date of employment separation (Date must be on or after 3/20/2020).

Are you or any member of you household receiving government assistance or benefits? (Select all that apply)

Housing Choice Voucher (Section 8)

Income-Based Housing (Housing Authority/HUD)

Social Security Benefits

SNAP Benefits (Food Stamps)

Women, Infants, and Children Program (WIC)

Medicaid

Child Care Subsidy

None of the Above

If you checked none of the above, have you applied for any of these services?

Yes

Do you need additional assistane? If yes, please check all that apply:

Employment Services

Housing Information

Financial Planning and Budgeting

Education Assistance

Personal Safety

Safety Net Benefits (health insurance, food stamps, cash assistance)

Child Care Assistance

I need to speak to a Counselor/Therapist

I need help with substance use issues

Would you like information or assistance with additional resources within Winston-Salem/Forsyth County?

Yes

Thank You

Please contact us for program and donation information.

P.O. Box 24032

Winston-Salem, NC 27114

(336) 331-3478

Journee Bees Village is a 501(c)( 3) organization. All donations are tax- deductible.

Journee Bees Village does not and shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, and vendors.