Stupp Employee Disaster Relief Fund Application
A red asterisk (*) indicates a required field.
Employee Name
*
First Name
Last Name
Age
*
Cell Phone Number
*
-
Area Code
Phone Number
E-mail
*
Physical Address at time of flood
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parish
*
Alternate Contact Name
*
First Name
Last Name
Alternate Contact Phone
*
-
Area Code
Phone Number
Relation to Contact
*
Your primary residence that was affected by the flood is/was:
*
Owned by you
Rented by you
Lived in, but owned by someone else
Number of dependents under the age of 18 living in the home
*
Number of dependents NOT living in the home
*
Example: children attending college
Total household income level:
*
Please Select
Less than $50,000
$50,001 to $100,000
Over $100,000
Amount of water in home
*
Please Select
Less than 12 inches
12 inches - 35 inches
36 inches - 60 inches
More than 60 inches
Additional Comments regarding the impact, physical damage or financial need.
Please upload up to 6 pictures of your loss/damage.
Upload a File
Cancel
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I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process.
Address to which the relief check should be mailed, if approved:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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