ALLEGANY COUNTY FLOOD RECOVERY INTAKE FORM

ALLEGANY COUNTY FLOOD RECOVERY INTAKE FORM - 2026
INTAKE BASICS
2-1-1 HelplineSelf-enteredAt an on-site flood eventOther
2. Today's date *

MonthDayYear
Date
YesNo
PERMISSION STATEMENT
4. The Intake Applicant listed below hereby grants permission to United Way of Cattaraugus & Allegany Counties to use the details provided in this document for the express purpose of coordinating and providing aid to the applicant and/or applicant's family following a disaster, effective at the date of intake and for the duration of the recovery efforts. No information will be altered without prior written consent, nor will it be used for commercial purposes. A collection of all data gathered may be used anonymously for educational or research purposes.
I grant my permissionI do NOT grant my permissionOther
Signature
5. First Name*
6. Last Name*
INTAKE APPLICANT INFORMATION
7. Primary phone number *
Format: (000) 000-0000.
MobileLandline
YesNo
10. Alternate phone number
Format: (000) 000-0000.
11. Email address
example@example.com
PhoneEmailText
13. What is the best time to reach you?
18-5960+
FemaleMaleNon-binaryPrefer not to say
SELF-REPORTED AT-RISK POPULATION
High medical need (oxygen, dialysis, etc.)ElderlyChildren (under 18)Individuals with disabilitiesIndividuals with limited English proficiencyHomelessOther
HOUSEHOLD OCCUPANT INFORMATION
17. Number of individuals living in household*
The value must be a number
18. Additional occupants' name, age, relationship to Applicant
NONECat(s)Dog(s)Other
YESNO
ACCESS TO DWELLING
No or minimal damage to drivewaySome damage, but does not affect accessThere is major damage that impedes access
YesNo
No damage to the bridgeSome damage but has been deemed safe; does not affect accessSustained damage making bridge unsafe; access impeded
YesNo
There was no damage to the rampThere was some damage, but it is still safe and does not affect accessDamage sustained makes the ramp unsafe; access impeded
DAMAGED DWELLING ADDRESS INFORMATION
26. Street address *
27. City *
28. ZIP *
The value must be a number
AlleganyCattaraugus
30. Town of residence *
YesNoNot yet, but plan to before any work begins and during the process
YesNoI haven't, but I will now and going forward
Single family structureMobile home (single wide)Mobile home (double wide)ApartmentDuplex / Multi-family homeBusiness / CommercialLand only
YesNo
OwnRent
36. If rental, what is the name and phone number of the landlord / property owner?
YesNo (please skip ahead to Question 40)
YesNoNot yet, but will work with CCE to do this
YesNoMaybeOther
AFFECTED (no damage affecting habitability; cosmetic damage; any waterline in the crawl space or an unfinished basement when essential living space or mechanical components are not damaged or submerged. Damage to a porch, carport, garage, and/or an outbuilding.)MINOR (when waterline has reached the floor system of trailer but has not entered the living space of the unit; no structural damage; trailer has not been displaced from the foundation; waterline at 1 to 3 inches in an essential living space. When waterline exceeds 3 inches but is below 18 inches, damage may be major or minor depending on the following factors: duration of the flood; contaminates in the water; if waterline reached outlets; and number of essential living spaces flooded. Any waterline in a finished basement.)MAJOR (water has covered the floor system and entered the living space of the trailer unit but still below the roofline; residence has been displaced from the foundation; waterline above 18 inches or the electrical outlets in an essential living space. Waterline on the first floor (regardless of depth) of a residence when basement is completely full. When waterline exceeds 3 inches but is below 18 inches, damage may be major or minor depending on the following factors: duration of the flood; contaminates in the water; if waterline reached outlets; and number of essential living spaces flooded.)DESTROYED (residence is a total loss; frame is bent, twisted, or otherwise compromised; waterline at the roofline or higher, or complete failure of two or more major structural components e.g. collapse of basement walls, foundation, walls, or roof.)INACCESSIBLE (property currently cannot be reached.)
YesNoUnsure
YesNo
43. What was the water level in the basement? (please specify in inches or feet)
YesNo
45. What was the water level in the essential living space? (please specify in inches or feet)
46. Briefly describe the damage:
YesNo
YesNoUnsure
YesNoUnsure
YesNoOther
YesNoUnknown at this time
YesNoUnknown at this time
CURRENT ADDRESS INFORMATION (if different from damaged dwelling)
53. Address where applicant is staying (if different than damaged dwelling)
YesNoNot sure
55. If temporary housing, is there a plan for where applicant(s) will go next if they can't stay here?
YesNoMaybe
SELF-IDENTIFIED DISASTER-CAUSED UNMET NEEDS
Shelter / Housing assistance (temporary/interim)FoodTreatment of illness or injury (replacing prescriptions, medical equipment, etc. lost to disaster)Assistance locating a person or family that is missing due to disasterBehavioral health access, crisis counseling, or spiritual and emotional careMold remediation assistanceDebris removalFinancial assistanceHousing repairs assistance (repair or rebuild of dwelling)Legal assistance (obtaining services or fees)Functional needs assistance with services, devices, and modifications (such as Braille or Large Print, Sign Language interpretation, easy-read versions, accessible toilets, etc.)Essential clothingEssential furniture and/or appliancesTransportation assistance (local travel, replacement vehicle, moving expenses)Employment (affected by disaster)Health insurance or healthcare accessFEMA registration (or appeals), if individual FEMA assistance is made availableUtilities assistanceAssistance with accommodating or caring for a domesticated animal or petFuneral cost assistanceAssistance with temporary storage of household itemsOther
BEHAVIORAL HEALTH ASSESSMENT
YesNo
YesNoMaybe
YesNo
CHILDREN AND YOUTH ASSESSMENT
YesNo
YesNo
YesNo
YesNo
65. If childcare is needed but child is not attending, what are the barriers? (ie: relocated to new area, provider center closed due to disaster, family care provider no longer able to provide care, etc.)
YesNo
YesNo
YesNo
YesNo
YesNo
INSURANCE / FINANCIAL
71. Fair Market Value of the property
YesNoUnsure
73. Name of insurance carrier
YesNoUnsure
YesNo
YesNo
77. Approximately how much?
YesNo
FINANCIAL ASSESSMENT
Pre-Disaster Financial Information
79. Annual household income*
80. If your household is income-eligible based on 200% of Federal Poverty Guidelines for family size, would the applicant like to be referred to Department of Social Services to determine eligibility for assistance (such as SNAP, HEAP, other government assistance)? NOTE: This does not determine eligibility for other forms of assistance.
YesNo
81. Monthly income (indicate gross or net)*
82. Monthly expenses*
Unemployment insuranceSupplemental security income (SSI)Social security disability income (SSDI)Veterans disability paymentNone of the above
YesNoUnsure
YesNo
FOOD ASSESSMENT
YesNoUndetermined
Assistance from local pantryMeals on WheelsWoman, Infant, and Children (WIC) benefitsSupplemental Nutrition Assistance Program (SNAP)Other
YesNoOther
CLOTHING
YesNo
Laundry AssistanceUsable Clothing for work or schoolShoes/bootReferral to faith-based/community organization for clothingOther
91. Note age, items, and sizes of clothing/shoes needed, if known
FURNITURE/APPLIANCES/PLUMBING/ELECTRIC ASSESSMENT
FurnitureAppliancesFurnaceHot Water HeaterPlumbingElectricHVAC/Duct WorkNONE OF THE ABOVEOther
YesNoNot yet, but plan to
YesNoNot yet, but plan to apply
YesNoUnsure
WHAT HAPPENS NEXT?

If you requested referrals to various services, those organizations will be contacted on your behalf. Eligibility for various resources will be determined; you will be contact for additional information, as needed. Based on eligibility, coordination of benefits and resources among community partners will be provided. Expect further follow up as the process unfolds.
THANK YOU!
Please verify that you are human*
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ALLEGANY COUNTY FLOOD RECOVERY INTAKE FORM - 2026

INTAKE BASICS

PERMISSION STATEMENT

INTAKE APPLICANT INFORMATION

SELF-REPORTED AT-RISK POPULATION

HOUSEHOLD OCCUPANT INFORMATION

ACCESS TO DWELLING

DAMAGED DWELLING ADDRESS INFORMATION

CURRENT ADDRESS INFORMATION (if different from damaged dwelling)

SELF-IDENTIFIED DISASTER-CAUSED UNMET NEEDS

BEHAVIORAL HEALTH ASSESSMENT

CHILDREN AND YOUTH ASSESSMENT

INSURANCE / FINANCIAL

FINANCIAL ASSESSMENT

FOOD ASSESSMENT

CLOTHING

FURNITURE/APPLIANCES/PLUMBING/ELECTRIC ASSESSMENT

WHAT HAPPENS NEXT?

THANK YOU!