House in Need Updated Form: 2015
We are updating our records and need the following information completed.
Sign in to Google to save your progress. Learn more
Basic Information:
Name *
Resident  Affected Address *
Town *
Telephone # *
Email Address *
Current Address
(if different than above)
Where you are now? 2015
If you are back in your home and feel comfortable in your situation, that is wonderful and you do not have to complete the rest of this form.  We will update your first application as complete.
Are you living at premises affected by Super Storm Sandy
Clear selection
Which rooms are still not completed?
How long do you think repairs will take?
Are you lifting your home?
Clear selection
Do you need mold remediation?
Clear selection
Do you need help budgeting/planning the rebuilding of your home?
Clear selection
Are you interested in selling?
Clear selection
Would you like a CMA to contact you with a recommendation regarding refinancing options.
Clear selection
 Do you need any Demolition work completed?
Clear selection
If you answered Yes to Demolition work, Please give us a brief description of what needs to be done.
Do you have neighbors not living back at home who need help with lawn care? If so, please give us their address.
We may have a group to mow lawns around town to help with your streets curb appeal
Are you stuck in the rebuilding stage because you have ran out of funds completely?
 There is no more insurance/FEMA money left.  You may comment below if needed.
Clear selection
What appliances have you not purchased yet?
Would you like to be contacted by someone for emotional support?
e.g. Project Hope, Support Groups in your area
Clear selection
Are you in need of furniture  at this PRESENT time?
Clear selection
If you responded Yes to previous furniture question, please provide a Brief description of what is needed or what rooms need furniture too.
Did you apply for NY Rising Grant?
Clear selection
Have you been assigned a NY Rising caseworker?, and/or Schedule an Appointment?
Clear selection
Besides previous questions....What do you feel that you need assistance with at the present time?  
Comments, Suggestions, and Concerns?
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy