Disaster Assistance Application

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Please fill out the below information as thoroughly as possible. The information that you provide will be able to help us understand what kind of assistance you need. Once you have completed and submitted the application one of our Long Term Recovery Group Case Managers will be in contact with you.

Head of Household Name: *

Current Address with City/State/Zip Code: *

Phone Number (###-###-####) *

Best times to call (e.g Monday/Friday - Mornings)

Email Address: *

Additional Phone Number or Email *

Number of Persons in Household Age 20-64: *

Number of Persons in Household Age 19 or Under: *

Number of Persons in Household Age 65+: *

Is there anyone in the household with special needs? *

Yes

Race/Ethnicity *

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other/Unknown

Prefer Not to Say

Which of the Following do You Need Disaster Assistance With? *

March 2019 Flooding

COVID-19

Both

Other:

Required

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