Types of Damage (check all that apply)
Provide a detailed description of loss incurred. Include physical location of damage (especially important if mailing address is PO Box or different than location of damage). Describe who is impacted. Number in household, size and makeup of group or community. Include quantity of loss/damage/expense, household items damaged, furniture, appliances, vehicles, number livestock, number of acres, number of additional miles to work/school/doctor. Describe other assistance you have applied for and results, if known.
To the best of your ability, based on actual costs and estimates as well as claims and assistance provided or qualified for, please complete the following. (Documentation may be requested)
Documentation Required: Utility bill or other verification of address. Documentation requested: Pictures of damage; invoices or quotes for remediation, repair or replacement of damaged items. Upload file size limit is 30 MB. If you have files that exceed that amount, please reduce the size of your files or provide them via email using the address below.
I agree to sign this application electronically and my electronic signature is the legal equivalent of my manual signature on this application.
All information provided is true to the best of my knowledge and is submitted by the applicant who sustained losses from the March 2019 storms.
I agree to pay back any distributions made based on false or fraudulent information.
Questions? Contact the Catholic Social Services Flood Relief Committee at firstname.lastname@example.org