Disaster Assistance Application
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: *
Pre Disaster Address with City/State/Zip Code: *
Current Address with City/State/Zip Code: *
Email Address: *
Best Phone Number to Reach You and Best Time to Call: *
Number of Persons in Household Age 20-64: *
Number of Persons in Household Age 65+: *
Number of Persons in Household Age 19 or Under: *
Is there anyone in the household with special needs? *
Race/Ethnicity *
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