TAYLOR CO. DISASTER RELIEF
APPLICATION
DONATE
Disaster Relief Application Form
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Indicates required field
Name
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First
Last
Which storm(s) were you impacted by?
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December 10/11, 2021
January 1, 2022
Both
Pre-Disaster Address Information
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Line 1
Line 2
City
State
Zip Code
Country
Current Address Information
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Primary Phone Number
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Text capable?
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Yes
No
Secondary Phone Number
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Text capable?
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Yes
No
Best time to call
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What type of Insurance is in place?
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Homeowner
Flood (Structure only)
Full auto coverage (comprehensive)
Renters
Flood (Contents)
None
Other
If other insruance is in place please explain
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Is Survivor
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Homeowner
Unhoused
Business owner
Renter
Landlord (or other non-primary home property)
Registered with FEMA
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Yes
No
Did FEMA refer survivor to SBA for loan?
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Yes
No
How many children under age 18 in household?
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How many individuals over age 65 in household?
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How many individuals between 18-64 in household?
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Risk Assessment - check all that apply
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Household with children under 18
Accessibility to home
Household displaced
Single head of household
Recovering from previous disaster
Experiencing ongoing distress
Medical Needs
No significant needs
Living in unsafe conditions
Household with functional and access needs
Damage under/uninsured
Household experienced loss of income
Basic urgent needs (food/water/shelter/etc.)
Limited or no access to transportation
English not primary language
Other
If other please explain
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Household Military Status
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N/A
Retired
Reserve/National Guard
Active Duty
Veteran
Current Need Advocacy
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Insurance
Landlord
FEMA
Local Government
SBA
Other
Check areas in which you need someone to provide assistance
If other please explain
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Was there a gap between what was paid by insurance and the amount of loss?
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Yes
No
If yes please explain
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Documentation must be provided to support claims of unmet needs. For example: insurance summaries or final statements, estimates, receipts, etc
Current Needs
Skip if no need.
Mark each need that relates to your situation by providing a brief description.
Exterior Debris Removal
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Interior clean-out
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Mold Abatement
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Chainsaw teams/tree clearing
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Food
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Clothing
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Baby needs
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Access and functional needs
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Temporary Housing
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Permanent Housing
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Medical/Medical Equipment
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Emotional/Spiritual Care
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Transportation
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Utilities
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Financial Assistance
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Household Appliances
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Household furniture
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Household needs - other
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Structural repairs
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Structural demolition
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Structural Rebuild
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Terrain Corrections
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Dozing, trenching, topsoil, etc.
Fencing Supplies
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Rebuilding Fences
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Building Materials
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If you have photos, quotes, please upload them below here:
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Max file size: 20MB
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UPLOADING DOCUMENTS
If you’re having issues uploading the documents here please email them to
taylorcodisasterrelief@gmail.com
and place applicants full name in the subject line.
We will follow up with you after you have submitted the info. Please be patient as we have a representative working to reach out to you.
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APPLICATION
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