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Mashall Fire and Wind Event Response Screening Form
Related Information
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Mashall Fire and Wind Event Response Screening Form
Marshall Fire response form
Primary Contact First Name
*
Primary Contact Last Name
*
Primary Phone Number
*
Email Address
*
Secondary Contact Name
Phone
Email
Number of Adults in Home
*
Number of Dependent Children
*
Ages of Persons in Household
*
Are there persons in the household with: (select all that apply)
*
A Disability
Elder Care Needs
Veteran Status
None of the above
Are you in stable and secure housing?
*
Yes
No
If Yes: List address
If No: Where are you currently staying and for how long?
How long is your post-address secure?
*
Less than 3 months
3-6 months
More than 6 months
Do you have ALE Insurance - Additional Living Expenses?
*
Yes
No
Date ALE Expires
Are you currently employed?
*
Yes
No
Did you lose wages and/or your employment due to this disaster?
*
Yes
No
If Yes: Please describe:
Other Immediate Urgent Needs As Result of the Marshall Fire
*
Food Instability
Loss of Transportation
Emotional Health Concern Need Referral
Behind on rent/utilities due to fire related expenses
Wind damaged home not fully repaired
Extreme smoke/heat/soot not fully repaired
Other
None
Please Describe Other Immediate Urgent Needs
Are you receiving regular case management from any other agency at this time?
*
Yes
No
If Yes: Please list agency name and description of services:
Pre-Disaster Address, City, and Zip
*
Was this your primary residence at the time of the fire?
*
Yes
No
Did you rent or own?
*
Rent
Own
Type of Residence
*
Single Family Residence
Mobile Home
Condo
Apartment
Duplux/Other
What type of damage occurred to the residence
*
Destroyed
Major
Minor
Outbuildings
If Outbuildings: Describe Outbuildings damage
*
If rebuilding do you need information regarding funding sources?
*
Yes
No
N/A
If rebuilding has permit been applied for?
*
Yes
No
N/A
If No: date you will apply:
Have you registered with FEMA?
*
Yes
No
N/A
If Yes: Describe Assistance
Do you need to continue with FEMA?
Yes
No
If Yes: Describe
Have you applied with SBA?
*
Yes
No
N/A
If Yes: Describe
Are you continuing with SBA?
*
Yes
No
N/A
If Yes: Describe
Do you have Insurance?
*
Yes
No
If Yes: Has insurance settlement been received?
*
Yes
No
If Yes: Describe
What are your plans for recovery, what is left to be completed?
*
Do you want assistance with your recovery plans?
*
Yes
No
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Foster Care Information
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First Name
*
Last Name
*
Email Address
*
Zip
*
I'm interested in: (Select all that apply)
*
Foster Care
URM Foster Care
Foster to Adopt
Long-term Foster Care
How did you hear about us?
*
Submit
Foster Care Information
×
Name
*
Phone Number
*
Email Address
*
Zip
*
I'm interested in: (Select all that apply)
*
Foster Care
URM Foster Care
Foster to Adopt
Long-term Foster Care
How did you hear about us?
*
Submit
Foster Care Information
×
First Name
*
Last Name
*
Email Address
*
Zip
*
I'm interested in:
*
Foster Care
URM Foster Care
Foster to Adopt
Long-term Foster Care
How did you hear about us?
*
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