Please fill out the form below, make sure to answer all questions.
Applicants must be residents of Utah.
Total amount not to exceed $500 of requested assistance. 

Relief Program Application
WE WILL NOT COVER MEDICAL RELATED EXPENSES. YOUR APPLICATION MAY BE REVOKED IF YOU ASK FOR FINANCIAL ASSISTANCE FOR MEDICATION OR OTHER MEDICAL COSTS ASSOCIATED WITH TREATMENT.
Other resources you have tried (check all that apply) *