Household Impact Intake Form

Household Impact Intake Form

For households that have been impacted by 2025 weather-related factors, please complete each field below to initiate the intake process.
Head of Household Name*

First NameLast Name
Household Size *
Number of Dependents
Housing Status Detail*

RenterHomeownerHomelessOther
Birthdate*

MonthDayYear
Date
Last Four of SSN*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Street Address

Street Address

Street Address Line 2
CityStateZip Code
Postal/Zipcode
Temporary Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Postal/Zipcode
County of Primary Residence
Veteran Status

YesNo
Disaster Incident Date

DayMonthYear
Date
Insurance Status

InsuredUninsured
Should be Empty: