WV VOAD Bridge Project Application
Application to apply for private bridge repair through WV VOAD.
Date of Disaster Event *
First Name *
Last Name *
Mailing Address *
City *
State *
Zip *
County *
Physical Address (if different from mailing)
Zip Code
Home Phone *
Cell Phone
Is the bridge your only access to your home? (If No, please describe your situation in more detail on number 38.) *
Are there children in the home that the bridge services? Under the age of 16 *
Does the bridge serve any residents that are over the age of 65? *
Are there anyone in the home that the bridge serves handicapped, bed ridden, or who require the use of mobility devices? (Walker, Mobility Chair, etc..) *
In the event of a life threatening emergency can an ambulance reach your home? Either through an alternate access point or your existing bridge? *
How many families does the bridge serve? *
Before the flooding what type of water crossing did you have? *
Have you received any type of federal or state dollars to help repair or rebuild bridge or water crossings? *
If yes, from whom?
What is the amount you received?
Attach any and all information on assistance provided by the state or federal government. Including FEMA and Small Business Administration Letters of approval or denial. (If no, Skip)
Do you have any financial or building resources to help rebuild or repair your bridge or water crossing? *
If yes, how much or what can you provide? Explain.
Are you employed? *
Do you receive disability or some other type of government program income? *
What is your monthly income (before taxes?) Enter amount only. If none enter 0 *
What is your household income? Include yourself and anybody else in the home that receives an income. (Include any and all income such as money from rental properties and other types of 1099 contractor payments) Enter amount only. If none enter 0. *
Can you verify your income with legal documents. i.e tax returns, pay stubs, award letters? *
Do you have a checking account? (You will be required at a later time to provide documentation, if approved) *
Do you have a savings account? (You will be required at a later time to provide documentation, if approved) *
Do you or anyone in the home have any other types of assets? i.e stocks, bonds, CD's (You will be required at a later time to provide documentation, if approved) *
#38, More to tell about your current hardships and transportation problems? Share your story here about what you and your family are enduring currently. Make sure to explain how you currently access your home and the date of disaster. Please be very descriptive and provide details. (If using paper application please write on additional pieces of paper if more space is needed.) *
Attach photos of the damage. Please attach no more than 5.
Do you certify that the above information correct best of your knowledge? *
Are you applying for yourself or are you applying for someone else? *
If yes what is your relationship to the person requesting assistance?
Do you have the applicants permission to submit this application on their behalf?
Signature of Applicant *
Signature of Authorized Person (if not applicant)
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