Hardin County Unmet Needs Questionnaire

Before completing this application, read the mission and description of Hardin County Strong below:

Hardin County Strong 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. These documents are listed at the end of this application. Your application will not be processed until all supporting documentation has been submitted in full.

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* 1. Do you live in Hardin County, Texas?

Yes

Only surveys completed on properties located within the boundaries of Hardin County, Texas will be considered. If you live outside of Hardin County, please call 409-246-5198 for assistance with finding resources available in your area.

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

Yes

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

Hurricane Harvey

Tropical Storm Imelda

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)

No Electricity

No Running Water

Furniture/Appliance Replacement

Other (please specify)

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

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* 6. Please provide reliable phone numbers for us to contact you:

Phone number 1:

Phone number 2:

Phone number 3:

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* 7. What is your PHYSICAL address?

Street/PO Box

City/State

Zip

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

Email Adddress 1

Email Address 2

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* 9. Head of Household Date of Birth:

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* 10. How many individuals live in your household?

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

Name / Date of Birth

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

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. Is your household a single parent household?

Yes

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* 16. Do you OWN or RENT your home?

Own

Rent

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

Site Built Home

Mobile Home

Other

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* 18. Are you employed?

Yes

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

Person 1:

Person 2:

Person 3:

Person 4:

Person 5:

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

Yes

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* 21. What is your monthly MORTGAGE or RENT payment?

Mortgage:

Rent:

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* 22. What is your monthly Homeowners and Flood Insurance premium?

Homeowners Insurance:

Flood Insurance:

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

Electric:

Natural Gas:

Propane:

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

Water/Sewer (average):

Garbage:

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* 25. 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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* 26. 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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* 27. Please provide the total, combined monthly amount paid for vehicle insurance coverage on all household vehicles:

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

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

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

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

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

Yes

If yes, what dollar amount is unpaid?

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* 34. Please describe the damages your home has sustained that remain UNREPAIRED:

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* 35. Please share other unmet needs you have that you need assistance with:

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* 36. Please share any additional information not listed in this survey:

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* 37. All information provided in this survey will require hard copies of documentation that clearly supports your responses. Please collect the following documents in preparation for this:
- Income statement(s) including social security and/or disability information and child support if you are a single parent with children
- Proof of ownership of your home (deed)
- All utility bills which must list the damaged address and your name
- All other bills including cable/internet/cell phone/car payment/insurance (car/property/health/other) prescriptions, etc.
- Copies of all loan and credit card documentation

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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* 38. Hardin County Strong is a 501c3 nonprofit organization that supports households impacted by disaster and other related circumstances. Our support is based on available funding. Cases are funded through an impartial case management process. Facts, beginning with the information requested in this survey, are collected and presented to a group of community volunteers that want to serve without pay or recognition. When they receive your case packet, it is void of all identifying/personal information including names and addresses. This assures all parties involved that cases are funded fairly and without bias. If funding is available and your case is approved, you will be notified of the next steps in our recovery process. Although we serve all Hardin County households, those that meet vulnerability requirements take precedence and are served first (indigent, elderly, disabled, veteran, single parent with underage children, first responder). It is the desire of Hardin County Strong to be an advocate for our community. We never stop working to find funding and resources to support Hardin County individuals and families.

Hardin County Strong
409-209-5400 (leave voicemail & we will get back with you)
www.hardincountystrong.org
Follow us on Facebook: Hardin County Strong

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* 39. Your online application will be sent directly to our office.

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

- Drivers License or State ID for every member in household over 18
- Social Security card for every member in household over 18
- Income verification documents for every member in household over 18 (pay stubs, disability letter, unemployment, child support, etc.)
- Bank statements for last 3 months
- Utility bill
(note: service must have been active during the event and clearly show the home address and name of the person requesting assistance)
- Home Ownership Documents/House Deed
- FEMA award/denial letter for the property
- Insurance award/denial information
- Photos of before/after storm
- Property tax statement showing taxes are current or applicant has a payment arrangement with the county

These can be emailed to:
director@JCLTRG.org
(your email will be acknowledged when received. If you do not receive an acknowledgment, call 209-5400 to verify)

Or hand-delivered to:
Michelle Brewer
**call to set up an appointment: 409-284-0856