Disaster Relief Application Please complete the application below to apply for assistance. You will receive acknowledgement of receipt of your applications within 48 hours (excluding weekends). If not, please email us. Date Completed* MM slash DD slash YYYY Choose Disaster*Winter StormLake CharlesOther* TCWW Member Non-Member TCWW Member #Church Affiliation Name* First Last Best Contact Number*Email* * Owner Renter Pre-Disaster Primary Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where are you currently staying?* Home Hotel Family/Friends Temporary Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Household InformationNumber in Household* Ages in Household* Choose one* Employed Retired Unemployed Immediate Needs AssessmentCopy of ID, photos of damage and current utility bill of impacted address required. HiddenCheck all that apply* Housing Home Repairs Food Clothing Appliances Transportation Reimbursement Check all that apply* Home Repairs Appliances Reimbursement Reimbursement amountAttach all receipts and documents below Damage Summary (describe damage to your home)*Other InformationHave the repairs been completed? Yes No Do you have a contractor? Yes No Have you registered with FEMA* Yes No Assistance needed with FEMA?* Yes No Do you have any of the following insurance?* Homeowner Renter Flood No Insurance Upload required documentation.*Maximum file size: 2MB Drop files here or Select files Max. file size: 2 MB. Consent* I agree to be contacted via phone and/or text by the Disaster Recovery Team to assist in my recovery efforts. Δ
