* 1. HFMA Member Number

* 2. Name

* 3. What is the best number to reach you?

* 4. What is your current address?

* 5. How many children are in your household?

* 6. What is/are the age(s) of your children?

* 7. Are you currently safe?

* 8. Do you have any immediate need(s)?

* 9. Will you be able to occupy your home in the near future? 

* 10. What is the estimated out of pocket expense to repair your personal property?

* 12. What type(s) of insurance do you have?

* 13. Has the storm significantly impacted your family's source of income?

* 14. Please share any additional comments:

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