Orange County Disaster Rebuild - Request for Assistance Questionnaire

Please complete the following questionnaire, which is the first step in recovery assistance:

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

Yes

Only surveys completed on properties located within the boundaries of Orange County, Texas will be considered. If you live outside of Orange County, please call 409-745-9719 for assistance with finding resources available in your area.

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* 2. I am reporting damages from the following storm:

Hurricane Harvey (2017)

Tropical Storm Imelda (2019)

Hurricane Laura (2020)

Hurricane Delta (2020)

Texas Winter Storm (2021)

May Flood (2021)

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

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

Phone number 1:

Phone number 2:

Phone number 3:

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* 5. What is your PHYSICAL address?

Street/PO Box

City/State

Zip

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

Email Adddress 1

Email Address 2

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* 7. Head of Household Date of Birth:

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* 8. How many individuals live in your household?

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

Name / Date of Birth

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* 10. Please list the name(s) and date(s) of birth for each individual in your household: (if you have more than 6 in your household continue with question 10)

Name / Date of Birth

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

Yes

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

Yes

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* 13. Is your household a single parent household?

Yes

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* 14. Do you OWN or RENT your home?

Own

Rent

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

Site Built Brick Home

Site Build Wood-frame Home

Pier and Beam Home

Single-wide Mobile Home

Double-wide Mobile Home

Modular Home

Other

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* 16. Condition of Home

Completely Destroyed

Severely Damaged

Moderately Damaged

Lightly Damaged

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* 17. Did your household receive Homeowner Insurance Funding?

Yes

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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:

- Drivers License or State ID
- Proof of Income (W-2, paycheck, Social Security info, etc.)
- Utility bills which must list the damaged address and your name
(note: service must have been active during the event and clearly show the home address and name of the person requesting assistance)
- Three Previous months bank statements
- 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

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. Orange County Disaster Rebuild 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 Orange 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 Orange County Disaster Rebuild to be an advocate for our community. We never stop working to find funding and resources to support Orange County individuals and families.

Orange County Disaster Rebuild
123 S. 6th St.
Orange, TX 77630
409-745-9719
mtubbleville@co.orange.tx.us
ocdisasterrebuild.com
Follow us on Facebook: Orange County Disaster Rebuild

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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
- Proof of Income (W-2, paycheck, Social Security info, etc.)
- Utility bill
(note: service must have been active during the event and clearly show the home address and name of the person requesting assistance)
- Three Previous months bank statements
- 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

These can be emailed to:
mtubbleville@co.orange.tx.us
(your email will be acknowledged when received. If you do not receive an acknowledgment, call 409-745-9719 to verify)

Or hand-delivered to:
Orange County Convention & Expo Center
OCDR Office
11475 FM 1442
Orange, TX 77630