ICUF Disaster Assistance Fund Application

ICUF Disaster Assistance Fund Application

Apply for financial assistance through the ICUF Disaster Assistance Fund. Please complete all required sections and provide supporting documentation as needed.
Applicant Information
Applicant Full Name

First NameLast Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
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.
Email Address
example@example.com
Credit Union Name
Title/Position at Credit Union
How long have you worked at or served on the Board at the credit union?
CEO Name
CEO Phone Number
CEO Email
Disaster Details
Specify the type of disaster.
Date disaster occurred

MonthDayYear
Date
Number of adults who live in the household?
Number of children under 18 who live in the household?
Choose one of the following to describe your living situation at the time of the disaster (Other examples: live with parents or other family):

Other
Were you mandated or strongly encouraged to evacuate your primary residence prior to the disaster?
Were you displaced from your home due to this disaster?
What are your current living arrangements after the disaster (e.g. primary residence, staying with friends or family, hotel, etc).
Did you experience a power loss for an extended period?
If yes, how long was the power loss (number of hours)?
Did you experience damage to your primary residence?
If yes, please describe damage to your primary residence.
Did you experience damage or loss to personal items that limit your ability to return to serving credit union members?
If yes, please describe.
Did you experience damage to your primary auto?
If yes, please describe damage.
Have you applied for federal disaster relief through FEMA (Federal Emergency Management Agency)?
If yes, please list the amount you received.
Has your credit union provided you with financial support during this time of need?
If yes, please list the amount you received.
Have you received financial support from other organizations for this disaster?
If yes, please list the amount you received.
Amount of assistance requested from the Illinois Credit Union Foundation (up to $1,000)
Total estimated out of pocket expenses expected to incur, plus out of pocket expenses that have already incurred due to the disaster and not covered by insurance/FEMA/ or other grants/gifts/assistance. (A dollar amount is required; please estimate to best of ability).
Please specify all costs included in the amount provided in your total out of pocket expenses. List the expenses separately and their costs.
Optional: Please provide any additional information necessary to identify your level of need and/or to further explain your situation that hasn't been outlined in previous questions.
Please upload supporting documents (e.g., proof of insurance adjustment, contractor estimate, pictures of damage/loss)

Cancelof
Certification & Acknowledgement
I, the undersigned, swear the provided information is true and all funds that I may receive will be used to aid me and/or my family with damage caused by the disaster indicated on this form .
I understand that the information provided on the application will be shared with the credit union CEO for confirmation.
I understand if awarded, this fund is a gift to you from the Illinois Credit Union Foundation. If this grant is associated with a qualified disaster, including a Presidentially declared disaster, it may be a qualified disaster relief payment for taxation purposes. ICUF does not offer legal or tax advice. Please consult with your attorney, accountant, or other qualified tax professional concerning the tax implications of this gift in your particular circumstances.
Applicant Signature
Date Signed

MonthDayYear
Date
Should be Empty:

ICUF Disaster Assistance Fund Application

Applicant Information

Disaster Details

Certification & Acknowledgement