APPLICATION FOR ASSISTANCE

 

This form shall be completed by the Case Manager.  This screening is helpful in determining whether or not a disaster-related need exists.  It will also determine whether this applicant fits your agency's requirements.  No phone interviews, please.  The phone is not meant to take the place of a face-to-face interview with a client.  Questions to begin:

 

Where were you and what happened at the time of the disaster?

What damage did you experience as a result of the disaster?

Have you received assistance from FEMA?  (if declared by Presidential Declaration)

What other agencies have given you help?  How or with what?

Did you rent or own your home?

Were you unemployed by the disaster?  Have you returned to work?  Where?

What about insurance?

What have you done so far about your recovery?

Have you written a recovery plan?

Do you plan to rebuild?  If so, have you obtained the building permits?

Have you obtained estimates for your repairs?

What about elevation…are you considering it?

Are you in a "buy out" area?

 

WARNING:  The information contained in this application is protected by the federal Privacy Act laws and must be kept completely confidential. Upon completion, the client is entitled to review its contents, comment upon it, and sign and date it.

 

Clients Name ___________________________________________________________________________

 

Spouse or Significant Other Name (if applicable) ______________________________________________

 

Pre-Disaster Address _____________________________________________________________________

 

Current Address ________________________________________________________________________

 

Phone (Current) ______________________________________Best Time to Call ____________________

 

Total Number Living in Home ___________________

 

___ Own   ___Rent

___ Single-Family Dwelling   ___ Multiple-Family Housing   ___ Duplex

___ Destroyed   ___ Major Damage   ___ Minor Damage

___ Insurance Coverage:   (  ) Structure   (  ) Contents

 

 

 

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #4, p. 53

Assistance Received

 

Federal Assistance received:  (Note: a signed FEMA Release of Confidential Information form is required in order to verify federal assistance)

___ Temporary Housing           Amount: _____________

___ Home Repair                     Amount: _____________

___ IFG                                   Amount: _____________

___ SBA Loan             Amount: _____________

___ Other (please specify) _____________________________ Amount: _____________

 

Assistance received from any other agency, such as American Red Cross or other faith-based organizations.  List type of assistance received (food, clothing, etc.) and dollar amount.

________________________________________________________________________________________________________________________________________________

 

Assistance received from family or friends.  List type of assistance and dollar amount.

________________________________________________________________________________________________________________________________________________

 

Are insurance, federal, state, and/or family resources sufficient to meet disaster-caused needs?

___ Yes   ___ No        If NO, please explain:

 

 

Home Owners Only:

Date Purchased: _____________

Price Paid: _____________

Balance Owing: _____________

Own the Land:  ___ Yes  ___ No

 

Recovery Plan

 

Has the family established a plan for recovery?  ___ Yes   ___ No

If YES, please describe:

 

 

 

 

What remains to be done?  Describe the individual's/family's stated unmet need(s).

Be specific.

 

 

 

 

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #4, p. 54

Have estimates for repairs or replacement of residence been obtained?  ___ Yes   ___ No

1.  Amount: $_____________ Contractor: ________________________________

2.  Amount: $_____________ Contractor: ________________________________

3.  Amount: $_____________ Contractor: ________________________________

 

Have permits/inspections been obtained:  ___ Yes   ___ No

 

Have elevation requirements been checked:  ___ Yes   ___ No

 

 

 

Case Manager's Assessment

 

Is long-term assistance needed?  ___ Yes   ___ No   If YES, please complete Disaster Assessment or Unmet Needs form, then submit a Requisition Form to your Case Supervisor.

 

Other Needs: (i.e., names/ages/sizes of children in household, underinsured landscaping, livestock loss, etc.)

 

 

 

 

Comments:

 

 

 

APPLICANT STATEMENT:  I agree and affirm that I am making voluntary application for assistance for disaster relief from the Long-Term Recovery Committee of Southwest Indiana (LTRCSI).  I understand that the information contained in this application and the accompanying Individual/Family Plan for Recovery and the Release of Confidential Information forms will be utilized by LTRCSI and all its members agencies to assist me with my disaster-related needs.  I understand that assistance is not guaranteed and that the Case Manager does not make the final determination of the availability of funds or other kinds of help.  My signature below signifies that I have read and/or understand this completed document and the service being provided me.

 

Signature of Applicant: __________________________________ Date: _____________

 

Signature of Co-Applicant: _______________________________ Date: _____________

 

Witness (Case Manager's signature): _________________________________________

 

 

 

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #4, p. 55

AN INDIVIDUAL or FAMILY PLAN for RECOVERY

 

 

Date: _____________

 

This is an agreement between ____________________________________________ and

                                                            Client signature

 

____________________________________________, a Case Manager representing the

                        Case Manager signature

 

Long-Term Recovery Committee of Southwest Indiana (LTRCSI).  This agreement is a

 

plan for the physical recovery of the above-named client/family whose property was lost

 

on _____________ in ________________________________________________.

            date                             name of disaster

 

Applications which remain to be completed:

 

FEMA _____   Insurance _____   SBA _____   IFG _____

 

Other Agencies __________________________________

 

Estimates to be acquired:

 

Repair __________ Rebuild __________

 

From (Contractor) ________________________________________________________

 

Furniture, Appliances, Automobiles/Transportation, and Other Physical Needs:

 

Estimate:  $__________  For What: ______________ From: _______________________

 

Estimate:  $__________  For What: ______________ From: _______________________

 

Estimate:  $__________  For What: ______________ From: _______________________

 

Estimate:  $__________  For What: ___Clothing___  From: _______________________

 

Other (list) ______________________________________________________________

 

________________________________________________________________________

 

(Continued on next page)

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #5, p. 56

(Continued from previous page)

 

The Client agrees to the following: (specify)

 

 

 

 

The Case Manager agrees to the following:

 

1.      To present the disaster-related need(s) that cannot be met through regular channels to the Long-Term Recovery Committee of Southwest Indiana.

2.      To assist the client when needed and go with the client, if needed, to act as an advocate before FEMA and/or other agencies.

3.      To inform the client of resources available to meet their disaster-related needs.

4.      Other: (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #5, p. 57