Phase 2 Funding Request Long-Term Recovery (8+ Days)

Disaster Relief Fund

Phase 2 Funding Request— Long-Term Recovery (8+ Days)

Due to the nature of long-term recovery, funding will be requested for the services the organization will provide to disaster victims—Disaster Relief Providers may submit more than one Phase 2 requests. Case management should be utilized by Disaster Relief Providers to accurately assess total need in determining what resources will be required to return client(s) to self-sufficiency (please note funding will generally not exceed $5000)*.

Organization Name: ______

Organization’s Address: ______

City, State, Zip Code: ______

Phone Number: ______

Fax Number: ______

Contact Person & Title: ______

Contact’s Email Address: ______

Contact’s After-Hours/Cell Phone Number: ______

Long-term Recovery Categories of Need

In the category(s) below please indicate what services your organization performs and the amount requested:

Long-term Recovery Categories$ Requested

Category 1 - Destruction of home

- Property is destroyed and cannot be repaired

- Home is primary residence

- Only home owned by affected party

- Needs unmet by FEMA and/or Insurance agency

- Specific services requested: ______

Category 1 Funding Request$ ______

Category 2 - Displaced-out of home or significant portions of the home

- Property heavily damaged but can be rebuilt

- Home heating system, wells or septic systems are not functional

- Survivor’s only vehicle is destroyed

- Medical displacement health related issues; respiratory problems being #1

- Due to mold or other issues (ex. Damage to structural building integrity, heat, water, etc.)

- Needs unmet by FEMA and/or Insurance agency

- Specific services requested: ______

Category 2 Funding Request $ ______

Category 3 - Other Residential Repairs

- Siding, flooring, and other important but nonessential components

- Essential furniture such as beds, kitchen tables and chairs, dressers

- Specific services requested: ______

Category 3 Funding Request$ ______

Category 4 – Quality of life issues

- Bedding, curtains and other items that will help restore quality of life

- Clothing, winter coats for kids

- Specific services requested: ______

Category 4 Funding Request$ ______

Category 5 – All other issues

- Home business loss

- Mitigation and excessive out of pocket expense

- Specific services requested: ______

Category 5 Funding Request$ ______

TOTAL REQUESTED$ ______

1. Describe the individual/family’s situation, including the extent of damage, total needs, and the amount of time client(s) have been experiencing unmet needs.

______

1. Has the individual/family requested help through the FEMA disaster assistance process?

Yes No

1. Has the individual/family requested assistance through their insurance company?

Yes No

1. Have you requested funding from any other organization/agency? If so, please specify:

______

Statement of Authenticity

All agency and program information contained herein is factual to the best of my knowledge. Our agency staff and/or chief volunteers are prepared to describe it to the Disaster Relief Fund Committee if needed. In addition, a funding report will be submitted after funds are utilized to account for grant monies and demonstrate services provided. Furthermore, in completing this form, the registrant agrees that no received funds shall be used for any administrative costs.

Signatures on this form indicate approval of all information contained within the
registration for funding.

Type Name - Executive Director or Chief VolunteerTitle

Signature - Executive Director or Chief VolunteerDate

* The completion of this form is not a guarantee of funding.
Funds will be disbursed on case-by-case basis.

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