Hurricane Helene Disaster Relief Intake Form

Hurricane Helene Disaster Relief Intake Form

Apply for assistance through Lutheran Services Carolinas' Disaster Relief program. Please complete all sections to help us assess your needs.
Applicant Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County
Post Disaster Address (if different)
We can only accept online submissions from the following counties in North Carolina: Buncombe, Henderson, Polk, and Watauga. If your county is not listed, please contact us with any questions.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Residence Information
Type of Residence
Do you own or rent?
Disaster Information
Disaster was the result of:

Other
Is the residence located on a Flood Plain?
Extent of Damage
Insurance Information
Do you have insurance?
Do you have flood insurance?
Insurance covers:
Was insurance sufficient to cover all the damages?
Employment and Income
Were you employed before the disaster?
Did you lose your job as a result of the disaster?
Monthly Income for All Household Members
Monthly Living Expenses
How many household members?
Individuals in Household
FEMA and Other Assistance
Did you apply for assistance from FEMA?
If yes, your FEMA case number:
If yes, did you also fill out the application for a SBA loan?
Assistance Received from FEMA/SBA
Assistance Received from Other Organizations or Agencies
Assistance Requested
Type(s) of Assistance Needed

Other
Describe specific needs
Do you have a plan for recovery?
If yes, please describe your recovery plan
What remains to be done?
Have you obtained estimates for repairs or replacement?
Amount of estimates
Have you obtained permits/inspections?
Applicant Statement
I agree and affirm that I am making Volunteer application for assistance for disaster relief from the Unmet Needs Project. I understand that the information contained in this application and the accompanying Individual/Family Plan for Recovery and the Release of Confidential Information form will be utilized by the Unmet Need Project to assist me with my disaster-related needs. I understand that the assistance is not guaranteed and that the case manager does not make the final determination of the availability of funds or other kinds of help. My signature below signifies that I have read and/or understand this document and the service being provided me.
Signature of Applicant
Date

MonthDayYear
Date
Case Manager’s Signature
Date

MonthDayYear
Date
Should be Empty:

Hurricane Helene Disaster Relief Intake Form

Applicant Information

Residence Information

Disaster Information

Insurance Information

Employment and Income

FEMA and Other Assistance

Assistance Requested

Applicant Statement