2017 Hurricane Disaster Assistance Request
Name
*
First Name
Last Name
Home Health Agency (HHA)
*
County of HHA
*
Are You an Employee
*
Yes, but I am unable to work.
Yes, I am currently working.
No.
Current Phone Number
*
-
Area Code
Phone Number
Original Phone Number
-
Area Code
Phone Number
Email Address
*
example@example.com
Original Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Insurance?
Yes
No
Percentage of home damage.
What is your Deductible?
Will insurance cover the full value of your home?
If not what is the difference in dollars?
Will insurance cover the contents of your home?
Yes
No
If not, what is the difference in dollars?
Is your automobile in working condition?
Yes
No
If not, what is your deductible?
Was you clothing ruined?
Yes
No
If you have insurance, when do you expect to receive compensation?
Have you Applied for FEMA assistance?
*
Yes
No
If so, what do you expect to receive from FEMA?
*
Have you applied for other kinds of assistance?
*
Yes
No
If so, please specify type and what you expect to receive from this other type of assistance...
*
What type of assistance are you requesting?
*
Food/Water
Clothing
Housing
Furniture
Would you like the assistance in...
*
Cash?
Items?
Services?
If cash, please specify requested amount.
*
Do you need temporary housing?
*
Yes
No
Where would you like the assistance delivered?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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