Benton County Community Affiliate-Ice Storm Assistance Application

Benton County Community Affiliate-Ice Storm Assistance Application

Through our Community of Excellence initiative and generous donations to the Benton County Community Affiliate Fund, we are able to provide monetary reimbursement/support if your family has been affected by the ice storm. Please fill out this form explaining the financial strain this storm has had on your family and we will try our best to support our community during this time of need. **Assistance is available as long as there are funds. Once all funds have been allocated, we will not be able to provide help until more funds are allotted.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How many people are in your household?*
What type of immediate assistance do you need?*

ShelterFoodHeatingMedical SuppliesOther
Gasoline Expense Amount ($)
Propane Expense Amount ($)
Food Expense Amount ($)
Generator Expense Amount ($)
How has the ice storm impacted your household. List all that apply.

Extended Power OutageNo heat in homeBurst or frozen pipesRoof, tree, or structural damage from iceUnsafe for impassable roadsLoss of income due to storm conditionsSpoiled food due to power lossOther
Please upload any receipts verifying purchases made during the winter related events pertaining to the above items. We understand that some may not have receipts for all transactions, but please provide what you can for documentation purposes. (Example: gas receipts for generators, estimates for debris removal, propane purchases, grocery receipts, etc).

Cancelof
Please describe your current situation and any further urgent needs so that we may be of assistance.*
Should be Empty: