Disaster Assistance Request Form

Disaster Assistance and Reimbursement Request Form

Please provide details about your household, property, and expenses to help us assess your needs.
Disclaimer: request form funds is not a guarantee.
Full Name

First NameLast Name
Email Address
example@example.com
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Address of damaged house

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How many people live in your household?
Please list the ages of all household members (separated by commas)
- Was your car damaged?
- Did you have insurance for the car?
- Are you the registered owner of the vehicle?
- What was the damage to your car?
- Vehicle Year
- Vehicle Make and Model
- What was your deductible? (USD)
- Are you seeking financial assistance or reimbursement?
- What is your current housing status?
  
  Other
- Did you have homeowners or renters insurance at the time of the tornado?
- Please describe the damage received by the storm
- Please describe any out-of-pocket costs you have incurred due to the tornado (e.g., repairs, temporary housing, supplies)
- Estimated total out-of-pocket expenses (in USD)
- Needs - Select all that may apply
- Please list all Assistance received
- In your own words, what are your biggest needs at this time
- What do you see to be your biggest needs in the near future
- Is there any additional information you would like to provide?
- Should be Empty:

Disaster Assistance and Reimbursement Request Form