Mashall Fire and Wind Event Response Screening Form

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Primary Contact First Name*

Primary Contact Last Name*

Primary Phone Number*

Email Address*

Secondary Contact Name

Phone

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)*

Are you in stable and secure housing?*

If Yes: List address

If No: Where are you currently staying and for how long?

How long is your post-address secure?*

Do you have ALE Insurance - Additional Living Expenses?*

Date ALE Expires

Are you currently employed?*

Did you lose wages and/or your employment due to this disaster?*

If Yes: Please describe:

Other Immediate Urgent Needs As Result of the Marshall Fire*

Please Describe Other Immediate Urgent Needs

Are you receiving regular case management from any other agency at this time?*

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?*

Did you rent or own?*

Type of Residence*

What type of damage occurred to the residence*

If Outbuildings: Describe Outbuildings damage*

If rebuilding do you need information regarding funding sources?*

If rebuilding has permit been applied for?*

If No: date you will apply:

Have you registered with FEMA?*

If Yes: Describe Assistance

Do you need to continue with FEMA?

If Yes: Describe

Have you applied with SBA?*

If Yes: Describe

Are you continuing with SBA?*

If Yes: Describe

Do you have Insurance?*

If Yes: Has insurance settlement been received?*

If Yes: Describe

What are your plans for recovery, what is left to be completed?*

Do you want assistance with your recovery plans?*