Screening Form for the Excluded Worker Fund | Columbia County Sanctuary Movement CRM

This is a screening tool and NOT an application. We are encouraging people to still fill out this form so we can work on ensuring you have the proper documentation to be able to apply if the fund opens again, as well as support anyone in the appeals process.

Today's date (mm/dd/yy) *

First Name *

Last Name *

Phone *

County *

Can we send you texts about relevant CCSM programs and immigration alerts? *

Yes No

What prevented you from applying if applying for the first time after 10/8/2021?

Did you live in New York State before March 27, 2020? *

Yes No

Do you live in New York State now? *

Yes No

Do you have a non-expired New York State driver's license, non-drivers ID, or DMV learner's permit; or an IDNYC that is currently valid or expired in 2020 or 2021? *

Yes No

Were you eligible for or did you receive any of the following benefits or income relief during the pandemic?

Unemployment Insurance *

Yes No

Were you eligible for or did you receive any of the following benefits or income relief during the pandemic?

Pandemic Unemployment Assistance (PUA) *

Yes No

Did you earn less than $26,208 in the 12 month period from April 20, 2020 to April 19, 2021? *

Yes No

Did you work before April 3, 2020 (before the COVID shutdown) at least 15 hours per week? *

Yes No

Did you lose 50% or more of your wages or income at some point between February 23, 2020 and April 1, 2021 because of COVID-related unemployment, partial unemployment, or inability to work? *

Yes No

Be sure to scroll to view all options. Must have a total of 4 points for Proof of Identity. Any documents that are not in English must be accompanied by a certified English language translation (applicants can self-certify translations).

Which of these proofs of identity do you have? (Check all that apply) - must have total of 4 points, including at least one with a photo *

Be sure to scroll to view all options. See next question for additional options. Must have either one document from this section or two from the next for Proof of Residency.

Which of these proofs of residency do you have? - must have one of these OR two from the next question *

Be sure to scroll to view all options.

OR two of the following, one dated before March 27, 2020 and one dated on or after March 20, 2021 (check all that apply) *

Be sure to scroll to view all options. Must have a total of 5 points for Tier 1 or 3 points for Tier 2 for Proof of Work History.

Which proof of work history do you have? (must have 5 points for Tier 1 or 3 points for Tier 2; check all that apply) *

Do you believe you have all the points and documents needed to apply? *

Yes No

Do you need help collecting any of the documents you listed? *

Yes No

Will you be applying through CCSM or on your own (or with another organization)? *

Is this your first time applying for the fund? *

Will you join the fight for $3 Billion in additional EWF so that you and others can receive pandemic support? *

Yes No

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