Name *

First Name

Last Name

Address

The address portion of this form is required if you are contacting us to request financial assistance.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What part of Humboldt County are you from? *

Southern Humboldt: Alderpoint, Alton, Carlotta, Hydesville

Northern Humboldt: Fields Landing, Humboldt Hill, Eureka, Bayside, Arcata, McKinleyville,

Eel River Valley: Bridgeville, Garberville, Redway, Scotia, Rio Dell, Fortuna, Ferndale, Loleta

Other:

Phone

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