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Relief Request Application
Please complete this form in one sitting. This form WILL NOT automatically save your progress as you go. If you need assistance completing your application, please contact us. A Relief Volunteer will contact you as soon as possible.
"
*
" indicates required fields
Unique ID
Recipient Contact Information
Name
*
First
Last
Email
*
Mobile Phone
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How Long Have You Been at Your Home Address?
*
Mailing Address is same as Home Address
Mailing Address is same as Home Address
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Language
Select
English
Spanish
Chinese
Mandarin
Cantonese
Hokkien
Tagalog
Vietnamese
Arabic
French
Korean
Russian
German
Other
Other Language
*
Marital Status
*
Select
Single
Married
Divorced
Separated
Widowed
Total Number of Residents
*
Including Adults and Children
Number of Adults
*
Adults 18+
Number of Children
*
Infant to 17 years old
Number of Pets
*
Resident Details
Leave fields BLANK if not applicable. Please use the (+) to add additional residents.
Adults
*
*Please indicate current military status in the Notes field: Active Duty, Reserves, Honorably discharged without disability, Disabled due to service, Retired (after 20 years of service).
First Name
Last Name
Age
Birthdate (MM/DD/YYYY)
Gender (M/F)
Military (Y/N)*
Shirt Size
Pant Size
Shoe Size
Missing (Y/N)
Special Needs (Y/N)
Notes
Add
Remove
Children
*
First Name
Last Name
Age
Birthdate (MM/DD/YYYY)
Gender (M/F)
Grade
Homeschooled (Y/N)
Shirt Size
Pant Size
Shoe Size
Missing (Y/N)
Special Needs (Y/N)
Notes
Add
Remove
Pets
*
Name
Type (Cat, Dog...)
Breed
Age
Gender (M/F)
Size/Weight
Missing (Y/N)
Notes
Add
Remove
Incident Details
Type of Incident
*
Select Incident
Agricultural Disease/Pests
Blizzard/Winter Storm
Drought/Water shortage
Earthquake
Emergency Disease
Extreme Heat
Fire/Wildfire
Flood/Flash Flood
Hail
Hurricane/Tropical Storm
Ice Storm
Incidents of Mass Violence
Landslides/Debris flow
Severe Storms
Sinkhole
Thunderstorms/Lightning
Tornadoes/Damaging Winds
Tsunami
Date of Incident
*
MM slash DD slash YYYY
Describe Impact
*
Please tell us the name of the natural disaster or incident you experienced, when it occurred, and how it impacted your family and home.
Accommodation Needs
Current Property Condition
*
Select
Destroyed
Damaged (Unlivable)
Damaged (Livable)
Not Damaged
Unknown
Accommodation Needs
*
Select
Need Temporary Living Accommodations
Need Temporary and Long-term Accommodations
Do NOT Need Temporary or Long-term Living Accommodations
Current Property Status
*
Select
Property Owner
Renting Property
Number of Rooms Needed
*
Requested Items (Immediate Needs)
List each of the items you're requesting in the categories below. You can skip any categories that do not apply. Please use the (+) to add additional items per category.
Gift Cards
Gift Card Type or Name
Value
Notes (If Applicable)
Add
Remove
Food Allergies & Restrictions
Please list any food allergies or restrictions such as peanuts, gluten-free, or kosher. Please use the (+) to add additional allergies or restrictions.
Allergy or Restriction
Notes (If Applicable)
Add
Remove
Baby / Toddler
e.g. Baby Food, Baby Formula, Stroller, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Diaper / Training Underwear Sizes
Type (Diaper or Training)
Preferred Brand (If Applicable)
Size
Notes (If Applicable)
Add
Remove
Animal
e.g. Pet Food, Leash, Kennel, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Bedding
e.g. Blankets, Pillows, Sleeping Bags, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Toiletry
e.g. Toothbrush, Toothpaste, Floss, Soap, Shampoo, Conditioner, Hair Care Products (such as leave-in conditioners and style products for natural hair), Brushes, Feminine Hygiene Products, Depends, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Education
e.g. Backpack, Notebook, Pencils, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Other
e.g. Space Heater, Computer/Laptop, Prescription Glasses or Contact Lenses, etc.
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Requested Items (Long-Term Needs)
Please list specific items such as Mattress, Desk, Table, Chair, instead of "Furniture" or Pickup Truck for Work, instead of "Vehicle"
Long-Term Items
Item Name
Quantity
Notes (If Applicable)
Add
Remove
Funding Request
Funding Received or Applied For (Select All That Apply)
*
None
Friends & Family
GoFundMe
GiveSendGo
Other Crowdfunding Website(s)
City, County, or State Sponsored Fund
Insurance Claim
Other
Amount Requested
*
If you do not need any financial assistance, enter $0.
Describe Funding Needs
*
Please describe the specific needs for which you are requesting financial assistance (for example: replace personal documentation (such as birth certificate), clothing, diapers, emergency expenses, essential household items, leasing deposit). Please include estimated costs. You may be required to submit copies of your receipts for these items.
Additional Resources
I'd like more information about the following resources:
Animals & Pets
Childcare
Education
Food Bank Support
Health Care
Homeschool
Mental Wellness
Military
Temporary / Permanent Accommodations
Other
Other Resources
*
Media Permission
Sharing Your Story
*
Sharing your story with donors and partners is the most effective way to help families like yours get the support they need. Do we have permission to share your story?
Yes, using my full name
Yes, using my first name and last initial (e.g. Jane D.)
Yes, using my first name only
Yes, anonymously
No, prefer not to share
Upload a Family Photo (Optional)
If you prefer that we not use your family photo when sharing your story, please DO NOT upload one.
Accepted file types: jpg, jpeg, gif, png, Max. file size: 50 MB.
Verification Documents
Upload Driver's License Photo
*
Please upload the front of your driver's license showing your permanent address. If your driver's license was lost or destroyed in the incident, please upload a recent photo of yourself.
Max. file size: 50 MB.
Upload Bill or Bank Statement
*
Please upload a copy of a bill or bank statement showing the address of the affected home
Max. file size: 50 MB.
Upload Photo Before Damage
*
Please upload a photo of your property BEFORE damages from the recent natural disaster or incident
Max. file size: 50 MB.
Upload Photo of Damage
*
Please upload a photo of damage to your property from the recent natural disaster or incident
Max. file size: 50 MB.
Agreement
Verification Reciepts
*
I understand I may be asked to provide purchase receipts for damaged or lost possessions for additional documentation requirements.
Verification Reciepts
*
I understand that FEC United does not guarantee all need requests will be met.
Accuracy of Information
*
I declare that the information provided is true and accurate. I also understand that any willful dishonesty may render for refusal of aid and assistance.
Signature
*
Signature Date
*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.