COVID-19 Assistance

Name*

First Last

Phone

Email*

Preferred Method of Contact*

Preferred Method of Contact

Do you need assistance paying a water bill, or getting water delivery for a cistern?*

Do you need assistance paying a water bill, or getting water delivery for a cistern?

Please explain your water need.

Please tell us about any other needs you have. Be as specific as possible.*

How much $ are you requesting to cover this need?

Were you referred to HRDC by another agency or organization?*

Were you referred to HRDC by another agency or organization?

If you answered yes, please list the organization.

Is there anything else we need to know about your situation or circumstance?