Home Assistance Request

If you are a homeowner - in the 77003, 77020, 77026 and 77028 zip codes - in need of assistance with cleaning, securing or mucking out your home due to damage from Hurricane Harvey please complete the information below so that we can add you to our list of neighbors in need. Volunteers are being assigned on an as-available basis to homes - first-come, first-served.

FWCRC can also help provide referrals for services or other information based on your current situation. We can provide referrals, resources, and/or information to anyone in the greater Houston area, but we are currently conducting clean-outs for eligible homes only in the 77003, 77020, 77026 and 77028 zip codes. For more info, contact our office at 713-674-0175 for questions or more information!

Email address *
First Name *
Your answer
Last Name *
Your answer
Street Address *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Was your home affected by the storm? *
Is your home currently livable or repairable? *
Do you own the home? *
Do you have any of the following: *
Required
Have you filed a claim for assistance with any of the following? (This will not affect the status of your request.) *
Required
Are you currently earning an income? (This will not affect the status of your request.) *
Required
Did you lose wages due to the disaster? *
Required
Are there children in the household? *
Required
If YES, Have the returned to school? *
Required
Do any of the following apply to you? *
Required
Please select the following types of assistance you are in need of (select all that apply) *
Required
NOTES on circumstances:
Your answer
Gender *
Date of birth *
MM
/
DD
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YYYY
Marital status *
Total number of people in the household: *
Your answer
Does everyone in your home speak English? *
Race? *
Required
Estimated annual household income? *
Required
Highest level of education? *
Required
Please complete the captcha before submitting the form.
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