Jeff Davis Hurricane Relief Fund

First and Last Name of the individual applying for assistance:*

First NameLast Name
Phone number where the individual applying for assistance can be reached during the workday:*
Please enter a valid phone number.
Physical Address for the property where assistance is being applied for:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List the names of all individuals who reside at the above address at least 50% of the year and their age:*
Email Address (if applicable) for the individual applying for assistance:
example@example.com

Our household's approximate annual income is $blanks* per year.
How many dependents are in the care of the individual applying for assistance?*

NoneOneTwoThreeFour or more
Does the individual applying for assistance have a physical disability or care for a dependent with a physical disability?*

YesNo

What is the total dollar amount of assistance being applied for?*
If applicable, is the property(ies) funds are being applied for insured? If yes, does your insurance cover any of the cost?*
Have you or anyone in your household attempted to receive FEMA/GEMA assistance for this request?*

YesNo
12. Please briefly describe the individual's financial need.*

0/1000
Briefly describe what funds are being requested for.*

0/1000
Please include pictures of damage, any decisions by insurance (if applicable), and/or decision letters by FEMA.

Cancelof
By signing my full name below, I certify that I have completed this application to the best of my ability. I believe the information included in this application to be correct and honorable.

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