Disaster Assistance Application - Jefferson County LTRG

This application takes 30-45 minutes to complete. Please read it completely and carefully.

Jefferson County Long Term Recovery Group (JCLTRG) assists vulnerable individuals and households with unmet needs related to natural or man-made disaster (example: Hurricane Harvey). We focus primarily on indigent, elderly, disabled, US veterans, or single parent households with underage children, however we do consider projects on a case-by-case basis. All cases are dependent upon available funding. If you have been impacted by a recent disaster/storm and have unmet needs as a result of the disaster (examples: need assistance with home repair or furniture/appliance replacement), please complete the following questionnaire, which is the first step in recovery assistance. You will be required to provide hard copies of specific supporting documentation in addition to this application. This documentation is outlined in detail at the end of this application. The documentation should be submitted in a timely manner. Your case will not be considered until your application and supporting documentation has been submitted in full. **It is not the responsibility of JCLTRG to remind you to submit the required documentation, although we will try to help you with this process as much as possible.

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* 1. Do you live in Jefferson County, Texas? (Our organization serves Jefferson County, TX. If you live outside of Jefferson County, please call our offices at 409-240-0331 and we will help direct you to a resource within the county you reside)

Yes

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* 2. Do you have unmet needs as a result of storm/disaster impact?

Yes

Other (please specify)

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* 3. What disaster/storm have you been impacted by?

Hurricane Harvey

Tropical Storm Imelda

Hurricane Laura

Winter Storm Uri

Other (please specify)

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* 4. Please check the appropriate choices that apply to your unmet needs as they relate to a recent storm/disaster impact:

Home Repair (outside)

Home Repair (inside)

Furniture/Appliance Replacement

Other (please specify)

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* 5. Head of Household (Full Legal Name):

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* 6. Please provide a reliable phone number(s) for us to contact you:

Phone number 1:

Phone number 2:

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* 7. What is your MAILING address?

Number/Street

City/State

Zip

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* 8. What is your PHYSICAL address?

Number/Street

City/State

Zip

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* 9. Please provide a working email address that you routinely check.

Email 1

Email 2

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* 10. Head of Household Date of Birth:

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* 11. How many individuals live in your household?

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* 12. Please list the name(s) and date(s) of birth for each individual in your household (exclude yourself):

Name / Date of Birth

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* 13. Do you have anyone in your household that is disabled?

Yes

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* 14. Do you have anyone in your household that is a US Veteran?

Yes

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* 15. Are you a single parent with children under the age of 18?

Yes

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* 16. If you receive child support, please list the monthly amount below:

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* 17. Do you OWN or RENT your home?

Own

Rent

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* 18. Which of the following best describes your home:

Site Built Home

Mobile Home

Other

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* 19. Are you employed?

Yes

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* 20. What is the name of the company/organization where you work or the name of your employer?

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* 21. Please provide the total monthly income for each person(s) in your household. Start with yourself: (you will be required to provide copies of supporting documentation)

Person 1:

Person 2:

Person 3:

Person 4:

Person 5:

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* 22. Do any members of your household receive social security, unemployment or disability (SSI) benefits?

Yes

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* 23. Do you have a MORTGAGE on your home? (Do you pay monthly notes to a bank or lender)

Yes

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* 24. What is your monthly mortgage or rent payment?

Mortgage:

Rent:

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* 25. What is your monthly homeowners and/or flood insurance premium?

Homeowners Insurance:

Flood Insurance:

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* 26. What is the amount of your monthly Electric/Natural Gas/Propane expense?

Electric:

Natural Gas:

Propane:

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* 27. What is the amount of your monthly Water/Sewer and Garbage expense?

Water/Sewer (average):

Garbage:

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* 28. What is the amount of your monthly phone/cable/internet expense?

Cell Phone 1:

Cell Phone 2:

Cell Phone 3:

Home Phone:

Internet/Wifi:

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* 29. Please list individual monthly car payment amounts for each household vehicle:

Monthly vehicle payment 1:

Monthly vehicle payment 2:

Monthly vehicle payment 3:

Monthly vehicle payment 4:

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* 30. Please provide the total combined monthly amount paid for vehicle insurance coverage on all household vehicles:

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* 31. Please provide an estimated monthly expense for gasoline:

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* 32. Please provide the total monthly prescription drug expense for all members of the household combined:

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* 33. Please provide total monthly payments for all outstanding loans/credit cards not included in previous categories mentioned above:

Credit Card 1:

Credit Card 2:

Credit Card 3:

Misc Loan 1:

Misc Loan 2:

Misc Loan 3:

Other expense:

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* 34. Please provide the total monthly amount spent by the household on food:

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* 35. If your household receives food stamps/SNAP, please provide that amount here:

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* 36. Do you owe outstanding county/property taxes?

Yes

If yes, what dollar amount is unpaid?

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* 37. Please describe the unrepaired damages to your home:

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* 38. Please describe other unmet needs that you need assistance with:

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* 39. Please share any additional information not listed in this application but you feel is important:

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* 40. Do you attest that all information you have provided in this survey is TRUE and CORRECT? (By choosing "yes" you are stating that all information you have provided is factual to the best of your knowledge)

Yes

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* 41. Jefferson County LTRG is a 501c3 nonprofit organization that supports the unmet needs of households impacted by disaster by providing direct services, advocacy or resources. We are not a government agency and do not receive government funding. Because we are working with many client applications, we cannot provide a timeframe for new application processing. Our services are based on available funding. We cannot guarantee that we will be able to fulfill your unmet needs. Your case will be considered in the order it was received and if funding is available. You may call our office for recommendations to other resources. Have you read and understood the information above? (by checking "Yes" you are attesting that you have read and understand the above information.)

Yes

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* 42. Jefferson County Long Term Recovery Group is not a construction business. We are not contractors. We are a not-for-profit organization that serves the public to the best of our ability. We are a small staff that makes a big difference through coordination, cooperation and collaboration with local, state and federal partners and many other organizations that are disaster missioned. Most of the funding we use to serve disaster impacted households is received through local donations, private donations, and grant funding. We do not receive any funding from the government. To be the best stewards of our funding and to serve as many households as possible, we aim to use volunteer labor to cut expensive repair costs. Because of this, our services are not immediate. Once we begin working in your home and depending on our volunteer pool, it could take months for us to complete the project. We will clearly communicate with you, to the best of our ability, the plan of action for your project and we will be transparent about our abilities as we move through the process. Have you read and understood the information above? (By checking "Yes" you are attesting that you have read and understand the above information)

Yes

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* 43. Do we have your permission to share your information with other vetted partner organizations that are providing assistance and/or funding for households impacted by disaster so that they may reach out to you? (If you check "no," you may miss opportunities to be provided assistance through other, trusted partner organizations.)

Yes

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* 44. Before finalizing and submitting your application please carefully read and record the information below so that you can begin collecting these documents. These documents MUST be submitted to our office after filing your application. CLICK HERE for a printable copy of the required supporting documents.

You are responsible for submitting hard copies of the following supporting documentation to our offices after completing your online application:

- Drivers License or State ID for all person(s) living in the home over the age of 17.
- Income statement(s) including social security and/or disability information and child support if you are a single parent with children
- Bank Statements (LAST 3 MONTHS)
- Utility bills (These must list the damaged address and your name)
- Monthly bills (ALL) including cable/internet/cell phone/car payment/insurance (car/property/health/other) prescriptions, etc.
- Outstanding loan and credit card documentation
- Home Ownership Documents/House Deed
- FEMA award/denial letter (if applicable)
- Insurance award/denial information (if applicable)
- Photos of before/after storm (if applicable)
- Property tax statement showing taxes are current or applicant has a payment arrangement with the county

CLICK HERE for a printable copy of the required supporting documents listed above

Email supporting documentation:
director@JCLTRG.org

Hand-deliver supporting documentation:
Call our offices at 409-240-0331 to set up an appointment to drop off paperwork.

IMPORTANT:
Once you feel like your application is complete and you understand what documents need to be provided to us to complete your application, you may submit your application by clicking the Blue Box below.