Full Name
*
Email
*
Summary of Damages
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Summary of Injuries
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Current Status of your home
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Did you Rent or Own your Home?
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Describe Current Living Situation
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Area of Need (check all that apply)
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Click on all that apply
Temporary Housing
Transportation Assistance
Basic Food & Supplies
Clothing
Storage Unit
Medical Assistance
Home Repair Assistance
Legal Assistance
Counseling & Emotional Support
Relocation Assistance
Job Search (if employer impacted as well)
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Description of Immediate Needs
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Are you currently receiving assistance from any other organization?
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Do you have insurance that will cover the damages?
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Select from List
Yes
No
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Details of Insurance Coverage
Any other hardships?
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Requested Amount
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Select from List
0-$500
$501-$1,000
$1,001-$2,500
$2,501-$5,000
$5,001-$10,000
$10,001-$20,000
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Certification of Information Provided
*
I certify that all information provided in this application is true and accurate to the best of my knowledge.
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