Mississippi People's Movement (MPM) Needs Assessment Form
After you fill this form out entirely you will be directed to fill out a form with the Mississippi Emergency Management Agency, **highly recommend** filling that form out, too
Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you rent or own your residence?
*
Rent
Own
Is your residence insured?
*
Yes
No
Mailing address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of residence
*
Phone number
*
Please enter a valid phone number.
Damage to home
*
Minor
Moderate
Severe
Do you have electricity?
*
Yes
No
Do you have running water?
*
Yes
No
Family members in your household including names and ages
Based on the hardships you are suffering currently, what supplies, services and/or items would be most beneficial to improving your current status?
*
Include clothing and shoes sizes, medical devices if any (be specific!), hygienic items, the need for power / running water, etc
Any images or documentation supporting your current condition? Please fill this out
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary files or uploads?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please verify that you are human
*
Submit
Should be Empty: