Hospitality Worker Emergency Relief Assistance Application

City of Seatte and Wellspring Family Services

The City of Seattle has partnered with Wellspring Family Services to provide one-time cash assistance to help meet the basic needs of workers in the hospitality industry impacted by the COVID-19 crisis. Please check eligibility guidelines before filling out this application. Application closes on February 15, 2021.

Privacy Policy

I understand that my records are confidential and protected by Federal and State Confidentiality Regulations and that information cannot be disclosed without my prior written consent unless otherwise provided for in the Regulations. Wellspring is committed to serve and recognizes that protecting that privacy and safety is essential to ensuring trust and future participation for applicants. All Hospitality Worker Emergency Relief Assistance applicants will be reviewed by Wellspring Staff and the City of Seattle for any auditing but will not be released for outside entities.

Household Information

First Name

Middle Initial

Last Name

Birthdate

Gender

Marital Status

Ethnicity

Primary language spoken in the household?

Primary Household Language Notes

Do you need a translator?

What is your phone number?

Can we leave voicemail at this number?

YesNo

What is your email address?

What was your last resident address you lived at in 2020?

Street

Unit

City

State

Zip Code

I declare that I am a City of Seattle resident.

Income/ Award Information

How much total income before tax did you receive in the past 30 days?

From July 1, 2020 - December 31, 2020 what was your total individual Income before taxes?

From July 1, 2020 - December 31, 2020 what was your total household Income before taxes?

How many people reside in the household?

How many dependents are there under the age of 18 in the household?

If approved for one-time assistance through this program, what is the best address to send your payment?

Street

Unit

City

State

Zip Code

Hospitality Job Information

What is/was your employer that qualifies you as a Hospitality worker?

Job Title

Managers Name

Mangers Phone Number

Employer Street

Employer City

Employer State

Employer Zip Code

Additional Census Information

Do you take care of elders who are on fixed incomes like SSI/SSDI and do they depend on your financial support? If so, how many?

YesNo

Number of elders supported?

Are you currently unemployed due to Covid?

YesNo

Have you had a reduction in hours due to Covid?

YesNo

Are you currently looking for work?

YesNo

If currently employed, is your work?

Comments

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Contact Information

American Indian or Alaska Native	Asian
Black or African American	Native Hawaiian or Other Pacific Islander
White	Prefer not to answer