SWLA Coalition Help Form

SWLA Coalition Help Form

In partnership with local and national organizations
SWLA Disaster Relief Coalition is partnering with local and national organizations to help repair or build new homes for qualified individuals or families. If you sustained damaged during Hurricanes Laura or Delta, Winter Storm Uri, the May Flood of 2021, or the Tornado of October 2021, we would like to walk along side you to see what resources are available to help you in your journey towards recovery.

By filling out this form:
- you are agreeing for this information to be shared to SWLA Disaster Relief Coalition (SWLA Responds, St. Bernard Project, The Fuller Center, and its affiliates)
- you understand that this is not a guarantee of work
- you understand that an organization may commit to only part of the work
- you understand that not all work may be done at one time
If you are looking for assistance with:

Food

Clothing
Shelter
Furniture
Utilities

Rental Assistance

Repair/Rebuild of Rental Properties

Please contact 211. We do not assist with these needs at this time.
Name *
Spouse's Name
I am filling out the form for: *

Myself A family member
If filling out form for someone other than yourself, please put their first and last name(s) and your relation to them.
Email
Cell Phone Number *
Address of the Need (include city, state, and zip code): *
Which best describes the property ownership? *

Homeowner: Primary Residence Homeowner: Non-Primary Residence Heir Property: Primary Residence Heir Property: Non-Primary Residence Renter
Do you own any additional properties? (Check all that apply) *

Yes, Heir (Family) Property Yes, Empty Lot Yes, Second House Yes, Mobile Home on Another Property No
Check all that apply to you: *

Disabled Single Parent Elderly Widowed First-Responder Veteran N/A
Were you living at this address prior to the storm? *

Yes No
Are you currently living in your home? *

Yes No
Referred by: *

Catholic Charities Fuller Center Mennonite Disaster Services St. Bernard Project Southern Mutual Help Association United Methodist Church Disaster Case Manager Friend Family Member Social Media Church Pastor
PROPERTY CONCERNS
What event caused the majority of your damage? *

Hurricanes Laura/Delta Winter Storm Uri May 2021 Flood October 2021 Tornado Other/not disaster related
Which best describes your home? *

1-Story on a Slab 1-Story Pier & Beam 2-Story on a Slab 2-Story Pier & Beam Mobile Home
Describe the damages to your home/your immediate needs: *
Check items below that you need assistance with: *

Tree(s) down that are blocking access to road Tree(s) on house Tree(s) down on property Home needs to be gutted (muck out) Home needs to be Mold Treated (shockwave, concrobium) Damage to roof Damage to windows Home was flooded Need new sheetrock Need new flooring Need foundation worked on (pier & beam) Need foundation worked on (slab) Need electrical worked on Need plumbing worked on
If you flooded, how many inches of water?
Do you have power? *

Yes No
Do you have electrical issues? *

Yes No Unsure
Do you have plumbing issues? *

Yes No Unsure
What repairs have been made to your home?
AVAILABLE RESOURCES
Do you have insurance? *

Yes No
If yes, did you receive any funds from your insurance? *

Yes No
If yes, do you have any funds left to aid in your recovery? *

Yes No
If yes, about how much do you have left to aid in your recovery?
If there are no remaining funds, type "0".
Do you have flood insurance? *

Yes No
Did you receive any funds from FEMA? *

Yes No
If yes, do you have any funds left to aid in your recovery? *

Yes No
If yes, about how much do you have left to aid in your recovery?
If there are no remaining funds, type "0".
Did you receive any funds from SBA? *

Yes No
If yes, do you have any funds left to aid in your recovery? *

Yes No
If yes, about how much do you have left to aid in your recovery?
If there are no remaining funds, type "0".
What were the funds used for? *
Do you have any other resources to contribute toward your recovery? (e.g., loan, grant, building materials, etc.) *

Yes No
If so, please list them here:
(E.g., Loan, Grant, Materials, etc.)
Employment Status: *

Employed Part-time Employed Full-time Unemployed Retired On Disability On Social Security
Do you have any other needs that you would like us to know about?
Prayer requests:
Admin ONLY:
Person Submitting
Should be Empty: