Expedited Application for Disaster Assistance

Expedited Application for Disaster Assistance

Please use this form for emergency disaster assistance only.

If your household is requesting assistance post disaster for loss of wages or repairs to the dwelling to make it habitable, please complete the regular Financial Assistance Application.

After completing this form, save as a PDF to your desktop.

Today’s Date:

Employee Information

Bookstore Employee Name:

Bookstore Name:

Store Location: City: State:

Hire Date:Month/Year / Last 4-digits of Social SecurityNumber:

Primary Phone: E-mail Address:

Best time to call:

Number of adults in household, including self: Number of dependents (under age 19):

Primary Household Information

Pre-disaster Address:

City: State: Zip Code:

Do you share housing expenses? Yes No

If yes, please explain:

Is this residence? Single family dwelling ApartmentMobile Home Other

Is this your primary residence? Yes No Do you: Rent Own

If renting: Name & Phone of Landlord

Current Living Arrangements

Where are you currently living? In pre-disaster home Withfamily With friends

Temporary housing

Current address (if not pre-disaster household):

City:State: Zip Code:

Description of Emergency and/or Hardship

Name of natural disaster:

Was your household part of a mandatory evacuation? Yes No

What are your immediate needs?

Housing Food Water Medical Clothing

Please provide any relevant additional details regarding the immediate needs due to the disaster:

Has the disaster worsened an existing disability or medical condition for you or a household member?

Yes No

If yes, please explain:

Emergency Community and Household Resources

Have you registered with FEMA? Yes NoRegistration #:

Have you applied or received Red Cross assistance? Yes No

Amount of assistance given: $

Do you have insurance (renters or homeowner)? Yes No

Have you contacted your insurance company? Yes No

What type of disaster insurance do you have (flood, tornado, wind)?

Will your insurance cover your losses? Yes No

Notes:

FEMA - Deadline to apply is 6 months from date of disaster; assistance is available for 18 months based on need. Any assistance from FEMA must be used for the purpose it is given and all receipts must be kept for 3 years. FEMA benefits are exempt from garnishment and taxes

Disaster Unemployment Assistance – Deadline to apply is 30 days from disaster (unless noted by the state).

If you have questions about the financial assistance program, your eligibility or about qualifying life events please refer to the application instructions document.

For office use only

Assistance amount awarded $Debit Card #

FedEx Tracking #

866-733-9064