Bull City Rebuilds Claim Form
This form is for individuals who were impacted by the explosion on April 10, 2019. The information gathered from this intake form will be used to assess need and distribute funds, however filling out this application does not guarantee funds. Individuals will need to show proof of impact.

Incomplete or invalid information will not be processed.

Please do not include any personal and private information on this form including, but not limited to, medical record numbers or social security numbers.

The deadline to submit an application is June 21st, 2019.

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