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First Name
*
Last Name
*
Client Identification Number (if applicable)
Which declared county are you currently in?
*
Sacramento
Amador
Alameda
Calaveras
Kern
Contra Costa
Santa Cruz
San Luis Obispo
San Benito
San Bernardino
Santa Barbara
San Jaoquin
San Mateo
Madera
Merced
Monterey
Mendocino
Mono
Tuolumne
Tulare
Ventura
Email address
*
Phone number
*
Preferred contact method
*
Email
Phone
Disaster Affected Address
*
City
*
Zip Code
*
Current Address (if different from disaster affected address)
Current City
Current Zip Code
Date of Birth
*
+
Total number of members residing in your household
*
1
2
3
4
5+
Any household members under age18 or over age 65+?
*
Yes
No
Not Applicable
Disaster Assessment
1. Were you affected by the disaster?
Yes
No
Unsure/Not Applicable
2. Do you have a stable place to live and/or can you meet your basic needs (food/shelter/clothing)?
Yes
No
Unsure/Not Applicable
3. Was your primary residence destroyed/rendered unlivable?
Yes
No
Unsure/Not Applicable
4. Did you own or rent?
Own
Rent
Not Applicable
5. Do you have home owners insurance?
Yes
No
Unsure/Not Applicable
6. Do you or any household members have any issues with AFN, literacy, language barriers, employment, legal, etc.?
Yes
No
Unsure/Not Applicable
7. Do you have material losses related to the disaster?
Yes
No
Unsure/Not Applicable
8. Do you receive social assistance (e.g., CFHL/SNAP, Unemployment)?
Yes
No
Unsure/Not Applicable
9. Do you need assistance navigating recovery resources?
Yes
No
Unsure/Not Applicable
I give Catholic Charities permission to temporarily store the data provided in this form.
*
Yes
No
Would you like to be contacted in the event that additional resources or disaster support is made available following a federal disaster declaration?
*
Yes
No
*If Yes, I acknowledge that I have read the
Release of Information
and consent to Catholic Charities contacting my household for the following (check all that apply):
*
To any agent, county, state or federal agency, designated to receive information relevant to my household request for any disaster support, including housing relief programs, currently or hereafter available as the result of this disaster
Only to any nonprofit organization that is participating in a FEMA or state recognized Long Term Recovery Group (LTRG)
Other-specify name of receiving individual or organization
No, I do not wish to be contacted
I understand that the release of this information does not guarantee that assistance will be provided; however, my authorization serves to maximize the opportunities to receive full support from all available local/state/federal resources.
*
clear
Survivor Notes/Comments:
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