Disaster Relief Assistance Application

Disaster Relief Assistance Application

This program aids approved individuals and families who have been impacted by a natural or man-made disaster to assist with related expenses. The amount of financial assistance available is based upon available disaster relief funding. Applications are usually reviewed within 5-10 business days.
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Please ensure all required documentation accompanies this application. Lack of documentation may result in a delay in the processing of the application.

Required documentation includes the following:
- Application, completed in full
- Proof of Income
- Copies of Any Bills/Items to be Paid with Funds (if applicable)
- Documentation Related to Proof of the Disaster
If you have difficulty completing the form or gathering any of the documents listed above, please contact Jill at 785-825-0208. Exceptions can be made.
Today's Date*

MonthDayYear
Date
Type of Disaster*

FireStormFloodOther
Date of Disaster Event*

MonthDayYear
Date
Applicant Information
County of Residence*
Applicant Name*

First NameMiddle NameLast Name
Applicant Date of Birth*

MonthDayYear
Date
Best Contact Phone Number*
Please enter a valid phone number.
This phone number is:*

CellHomeWorkMessage Only
Email*
example@example.com
Housing Information
Current Living Situation*

Pre-Disaster HomeFamilyFriendsTemporary HousingOther
Address at Time of Disaster*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Residence*

Single-Family DwellingApartmentMobile HomeOther
Do you rent or own this residence?*

RentOwn
Landlord Name
Landlord Phone Number
Please enter a valid phone number.
Mortgage Holder
Household Information
How many females age 0-17 live in your household?*
How many males age 0-17 live in your household?*
How many females age 18-64 live in your household?*
How many males age 18-64 live in your household?*
How many females age 65+ live in your household?*
How many males age 65+ live in your household?*
How many total people live in your household?*
Include children, roommates, etc.
Annual Gross Family Income*
Be sure to include child support, spousal maintenance, social security, disability, and all employment.
Source of Income (employment, child support, social security, etc.)*
Upload Proof of Income (check stubs, etc.) - if available

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Do you have homeowner's or rental insurance?*

YesNo
Was this housing subsidized by:*

HUD/Section 8HUD/FHANoneOther
Is this your primary residence?*

YesNo
Did you share housing expenses?*

YesNo
Please explain how housing expenses are shared among the household:
Is anyone in your family: (Check all that apply)*

Active MilitaryVeteranClergyDisabledElderlySingle ParentMedical or Mental Problems (describe below)Non-US Citizen (list citizen country below)Needs an interpreter (list language below)None of the above
Explain here:
Disaster Assistance
Has FEMA inspected the property?*

Yes.No.
Have you received any FEMA assistance?

No.Payment is pending.Yes.
How much have you received through FEMA?
How much do you expect to receive through FEMA?
Have you received anything from:*

Red CrossSalvation ArmyChurches/OrganizationsNoneOther
Please share what you received from each entity:
Insurance - Have you filed with your insurance?*

Yes.No.
Have you received any insurance payments?

No.Payment is pending.Yes.
How much have you received through your insurance?
How much do you expect to receive through your insurance?
Please provide any background information regarding the disaster and your current situation:*
How will you use the funds, if approved for assistance through Catholic Charities?*
Documentation Related to Proof of Disaster (if available)

What qualifies? Copy of FEMA Damage Assessment Letter; Copy of American Red Cross Damage Assessment Form; American Red Cross referral form with details of damage; Emergency Management Damage Report and Map
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Documentation of Bills/Expenses Related to Disaster to Be Paid (if available)

Bills, Quotes, etc.
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Applicant Signature

Clear
Should be Empty:

Disaster Relief Assistance Application

Applicant Information

Housing Information

Household Information

Disaster Assistance