Hurricane Harvey Survivor Assistance Form
Please "fully" complete this form to give the Port Arthur Long Term Recovery Team, non-profits and other disaster relief agencies, vital information about your needs in order to receive available short and long-term assistance. The Port Arthur Long Term Recovery Team will serve individuals and families that have a residence in the City of Port Arthur, Groves, Port Neches and Nederland area. For questions, please call 409.300.3707 (Monday-Saturday, 10AM-6PM).

If you do not have a FEMA#, please visit www.DisasterAssistance.gov to obtain your FEMA#. You may also apply by phone at 800-621-3362 (voice, 711 or VRS) or 800-462-7585 (TTY). Thank you!
Email address *
FEMA Number *
01-1234567 format
Your answer
First Name *
Your answer
Last Name *
Your answer
Spoken Language *
Phone Number *
Primary contact's cell phone number (Format: xxx-xxx-xxxx)
Your answer
House Number *
Example: "1122" - Enter JUST the address number, do not include apartment number here.
Your answer
Street Name *
Example: "Doering Lane"
Your answer
Building / Apartment / Unit Number
Your answer
City *
Your answer
Affected Home: State *
Affected Home: Zip *
Your answer
Affected Home: What County are you in? *
Your answer
Emergency Contact's Information (ECI)
Example: Spouse, Parent or close friend. If survivor does not have an emergency contact
(ECI): Full Name *
Emergency contact name
Your answer
(ECI): Relationship *
Emergency contact relationship (e.g. Spouse)
Your answer
(ECI): Cell Phone *
Format: xxx-xxx-xxxx
Your answer
(ECI): Email *
Your answer
EC: Address *
(Full address with city, state and zip)
Your answer
Local Support System (LSS)
Does your family have a support system consisting of any of the following
LSS: Home Church / Affiliation (if any) *
Name of church or denomination or "NONE"
Your answer
LSS: Home Church / Affiliation (level of involvement) *
LSS: Church *
Are you connected with a local church to help you/your family get back on your feet?
LSS: Friends *
Do you have friends that can help you/your family get back on your feet?
LSS: Other (list other local support for you)
Your answer
LSS: Has your local support been notified? *
Household Members
Number of total household members *
People with disabilities within household? *
Military veterans within household? *
Elderly within household? (Over 65) *
ATTN Data Entry Volunteer: Please count up the total and enter it
Household Members (Please list everyone in your household)
HHM 1 First Name (should be head of house) *
Your answer
HHM 1 Last Name *
Your answer
HHM 1 Age *
Your answer
HHM 1 M/F *
HHM 1 Employed *
HHM 1 Marital Status *
Household Member 2
HHM 2 First Name
Your answer
HHM 2 Last Name
Your answer
HHM 2 Relationship to Head of Household
Your answer
HHM 2 Age
Your answer
HHM 2 M/F
HHM 2 Employed
HHM 2 Marital Status
Household Member 3
HHM 3 First Name
Your answer
HHM 3 Last Name
Your answer
HHM 3 Relationship with Head of Household
Your answer
HHM 3 Age
Your answer
HHM 3 M/F
HHM 3 Employed
HHM 3 Marital Status
Household Member 4
HHM 4 First
Your answer
HHM 4 Last
Your answer
HHM 4 Relationship to Head of House
Your answer
HHM 4 Age
Your answer
HHM 4 M/F
HHM 4 Employed
HHM 4 Marital Status
*** Need more household members? ***
If you need more places to enter more than 4 people into the household, keep filling out the rest of the form and then click next to go to the next page to enter more household members.
Pet Information
Pets? *
# of Dogs *
1 Dog
8 Dogs
# of Cats *
1 Cat
8 Cats
Pets: Other
Your answer
Is there MORE THAN one family living in the home? *
How many additional FAMILIES live in your home (if NONE, write NONE)? *
Your answer
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Dwelling
Is the affected address your primary residence? *
Do you rent or own your home/apartment/rv? *
Have you applied for FEMA assistance? *
Type of Dwelling *
What kind of building is it?
My house has working: *
Required
Has FEMA assessed your home? *
Please tell us how high the water was in your home (water level mark)? (best estimation) *
Required
Insurance
Type of Insurance *
Have you submitted a claim to your insurance company? *
Did you have FLOOD Insurance on your home? *
Did you have Insurance on your Home Contents? *
Has Insurance Company assessed your home? *
Automobile
Was your automobile(s) affected? *
How many vehicles were destroyed due to the disaster? *
Your answer
Did you have Auto Insurance? *
Vehicle Insurance: Liability ONLY *
The number of vehicles with ONLY liability coverage (the type of insurance)
Vehicle Insurance: Full Coverage *
The number of vehicles with FULL Insurance coverage (the type of insurance)
Do you have any working transportation? *
Do you have a way to get around/get to work?
Transportation Comments
Example: we are borrowing our friends car
Your answer
Immediate Needs
Please list all of your IMMEDIATE NEEDS
Immediate: Do you have shelter/a home to live in? *
Immediate: Do you need food? *
Immediate: Do you need clothing? *
Immediate: Do you need medical help? *
Immediate: Do you need emergency financial assistance? *
Do you need food delivered to you? *
Has your home been mucked-out (sheet rock/carpet/wet belongings have been removed)? *
Has your home been sprayed for mold? *
Do you need assistance with debris removal? *
Has your neighborhood been provided with dumpster assistance? *
Would you like someone to help you muck out your house (remove all wet sheetrock, carpet, belongings, etc..)? *
Do you want someone to spray your house for mold? *
Where is the debris (check all that apply)? *
Required
Current Accommodations *
Where are you currently staying? (enter N/A if it does not apply)
Your answer
How long can you stay at this site? *
Your answer
Please give us the full address (including zip) *
Your answer
Important Facts
Please share your story with us
Your answer
Special Needs
Do you have any special needs we need to be aware of?
Your answer
Information Release Statement *
Austin Disaster Relief Network has my permission to share and exchange my information to the Long-Term Recovery Team, local and national non-profits and relief agencies assisting in Hurricane Harvey disaster response efforts. I confirm that 100% of everything I have stated on this application is TRUE. I understand that if I do not tell the truth, potential future assistance will be withheld from me and my family. When stating YES, I am giving a digital agreement to the above info.
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