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Disaster Relief
Marshall Fire and Wind Event Response
Marshall Fire Wind Event Screening Form
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Marshall Fire/Wind Screening
Primary Contact Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Secondary Contact Name
First
Last
Phone
Email
Household Information
Number of Adults in Home
(Required)
Number of Dependent Children
(Required)
Ages of Persons in Household (separate each age listed with a comma)
(Required)
Are there persons in the household with: (check all that apply)
(Required)
A Disability
Elder Care Needs
Veteran Status
None of the above
Current (Post-Disaster) Address/Living Situation
Are you in stable and secure housing?
(Required)
Yes
No
If yes, list address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If no, where are you currently staying and for how long?
(Required)
How long is your post-address secure?
(Required)
Less than 3 months
3-6 months
More than 6 months
Do you have ALE Insurance - Additional Living Expenses?
(Required)
Yes
No
Date ALE expires:
(Required)
Month
Day
Year
Employment
Are you currently employed?
(Required)
Yes
No
Did you lose wages and/or your employment due to this disaster?
(Required)
Yes
No
Please describe:
(Required)
Other Immediate Urgent Needs As Result of the Marshall Fire
Please check all that apply:
(Required)
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:
(Required)
Are you receiving regular case management from any other agency at this time?
(Required)
Yes
No
Please list agency name and description of services:
(Required)
Pre-Disaster Address and Situation
Pre-disaster Address
(Required)
Street Address
City
ZIP Code
Was this your primary residence at the time of the fire?
(Required)
Yes
No
Did you own or rent?
(Required)
Own
Rent
Type of Residence:
(Required)
Single Family Residence
Mobile Home
Condo
Apartment
Duplex/Other
What type of damage occurred to the residence:
(Required)
Destroyed
Major
Minor
Outbuildings
Describle Outbuildings damage
(Required)
If rebuilding do you need information regarding funding sources?
(Required)
Yes
No
N/A
If rebuilding has permit been applied for?
(Required)
Yes
No
N/A
If no, date you will apply:
(Required)
Have you registered with FEMA?
(Required)
Yes
No
N/A
Describe assistance:
(Required)
Do you need to continue with FEMA?
(Required)
Yes
No
N/A
Describe:
(Required)
Have you applied with SBA?
(Required)
Yes
No
N/A
Describe:
(Required)
Are you continuing with SBA?
(Required)
Yes
No
N/A
Describe:
(Required)
Insurance
Do you have insurance?
(Required)
Yes
No
Type of insurance:
(Required)
Homeowners
Structure
Contents
Renters
Other
Has insurance settlement been received?
(Required)
Yes
No
N/A
Describe:
(Required)
What are your plans for recovery, what is left to be completed?
(Required)
Do you want assistance with your recovery plans?
(Required)
Yes
No
CAPTCHA
Marshall Fire/Wind Screening
Primary Contact Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Secondary Contact Name
First
Last
Phone
Email
Household Information
Number of Adults in Home
(Required)
Number of Dependent Children
(Required)
Ages of Persons in Household (separate each age listed with a comma)
(Required)
Are there persons in the household with: (check all that apply)
(Required)
A Disability
Elder Care Needs
Veteran Status
None of the above
Current (Post-Disaster) Address/Living Situation
Are you in stable and secure housing?
(Required)
Yes
No
If yes, list address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If no, where are you currently staying and for how long?
(Required)
How long is your post-address secure?
(Required)
Less than 3 months
3-6 months
More than 6 months
Do you have ALE Insurance - Additional Living Expenses?
(Required)
Yes
No
Date ALE expires:
(Required)
Month
Day
Year
Employment
Are you currently employed?
(Required)
Yes
No
Did you lose wages and/or your employment due to this disaster?
(Required)
Yes
No
Please describe:
(Required)
Other Immediate Urgent Needs As Result of the Marshall Fire
Please check all that apply:
(Required)
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:
(Required)
Are you receiving regular case management from any other agency at this time?
(Required)
Yes
No
Please list agency name and description of services:
(Required)
Pre-Disaster Address and Situation
Pre-disaster Address
(Required)
Street Address
City
ZIP Code
Was this your primary residence at the time of the fire?
(Required)
Yes
No
Did you own or rent?
(Required)
Own
Rent
Type of Residence:
(Required)
Single Family Residence
Mobile Home
Condo
Apartment
Duplex/Other
What type of damage occurred to the residence:
(Required)
Destroyed
Major
Minor
Outbuildings
Describle Outbuildings damage
(Required)
If rebuilding do you need information regarding funding sources?
(Required)
Yes
No
N/A
If rebuilding has permit been applied for?
(Required)
Yes
No
N/A
If no, date you will apply:
(Required)
Have you registered with FEMA?
(Required)
Yes
No
N/A
Describe assistance:
(Required)
Do you need to continue with FEMA?
(Required)
Yes
No
N/A
Describe:
(Required)
Have you applied with SBA?
(Required)
Yes
No
N/A
Describe:
(Required)
Are you continuing with SBA?
(Required)
Yes
No
N/A
Describe:
(Required)
Insurance
Do you have insurance?
(Required)
Yes
No
Type of insurance:
(Required)
Homeowners
Structure
Contents
Renters
Other
Has insurance settlement been received?
(Required)
Yes
No
N/A
Describe:
(Required)
What are your plans for recovery, what is left to be completed?
(Required)
Do you want assistance with your recovery plans?
(Required)
Yes
No
CAPTCHA
EN
ES
EN
