Disaster Response - Individual Assistance Request
Please fill out the form below. Additional information is available at www.txrecovers.org
Full Name *
Your answer
Street Address (Damaged House) *
Your answer
City, State, Zip *
Your answer
Email address
Your answer
Main Phone Number (home) *
Your answer
Current Address (if different from above)
Your answer
Current Phone (if different from above)
Your answer
Name of Contact Person and Phone who can reach you
Special Needs
Please indicate any special needs in any exist in the appropriate spaces below
Special Needs - Elderly (please indicate number in each family)
Your answer
Special Needs - Single Parent (please indicate number in each family)
Your answer
Special Needs - Family (please indicate number in each family)
Your answer
Special Needs - Medical (specify condition)
Your answer
Special Needs - Handicapped (specify condition)
Your answer
County *
Your answer
UMC District
Your answer
Referred By
Your answer
Referral Phone Number
Your answer
Flood Insurance *
Home Owner's Insurance *
Has House Been Mucked/Gutted *
Needs
Your answer
Other Agencies Contacted
Your answer
FEMA no.
Your answer
Referral or Action Taken
Your answer
A case manager will follow up with you to evaluate your case to see if we can help you.
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