Any household members under age18 or over age 65+? *

Disaster Assessment

1. Were you affected by the disaster?
2. Do you have a stable place to live and/or can you meet your basic needs (food/shelter/clothing)?
3. Was your primary residence destroyed/rendered unlivable?
4. Did you own or rent?
5. Do you have home owners insurance?
6. Do you or any household members have any issues with AFN, literacy, language barriers, employment, legal, etc.?
7. Do you have material losses related to the disaster?
8. Do you receive social assistance (e.g., CFHL/SNAP, Unemployment)?
9. Do you need assistance navigating recovery resources?
*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): *
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. *
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