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Horry County Home Owner Application For Assistance
We are so sorry that your family has been affected by this current disaster. Please fill out this application for assistance and we will be in touch with you as soon as possible. The more information you give us in this application will speed up how quickly we can get a team to assist your family. **You must live in Horry County and be the primary homeowner and resident to request or receive assistance.
Zone (Office Use Only)
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Status (Office Use Only)
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Assigned Team (Office Use Only)
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Last Name *
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First Name *
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Address of Affected Home *
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City *
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State *
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Zip Code *
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Home or Cell Phone *
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E-mail Address
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Do you own or rent your home? *
My home is a: *
Repairs needed *
Required
Disaster Release of Personal Information For Assistance
On behalf of my household, I, the undersigned, authorize the Federal Emergency Management Agency (FEMA), the South Carolina Department of Social Services, SC-Emergency Management Department, my local county Emergency Managment Department, IMPACT Ministries of Myrtle Beach, Waccamaw VOAD Partners, Catholic Charities of the Diocese of Charleston, Inc., local Long Term Recovery Group partner agencies and case management agencies, as well as the Coordinated Assistance Network (CAN) partners to disclose personally identifiable information and/or confidential information relating to the potential financial or other forms of assistance needed for my household, arising from this current disaster. It is given to obtain and/or provide assistance I need as a result of this declared disaster to:
PLEASE CHECK ONE OR MORE OF THE FOLLOWING: *
Required
For the purpose of ensuring that: Benefits are not duplicated and appropriate referrals for possible and/or potential services provided by other state, nonprofit, and/or faith-based organizations can be made on my behalf. PLEASE CHECK ONE OR MORE OF THE FOLLOWING (NOTE: CONSENT TO ANY OF THE FOLLOWING OPTIONS IS VOLUNTARY): *
Required
Signature of Applicant Providing Consent
I declare, under penalty of perjury, that the foregoing is true and correct. I am freely giving my consent on this date listed below. This consent expires one year from this date. This information is not to be used for any other purpose.
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By typing my name below, I am agreeing to electronically submit my information to request assistance as outlined above for my home and family. (Type Name Below) *
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