APPLICATION FOR DISASTER IMPACTED PERSONS

DEMOGRAPHICS

Names of Applicants:

Pre-Disaster Address:

Pre-Disaster City:

Pre-Disaster State:

Pre-Disaster Zip Code:

Current Address:

Current City:

Current State:

Current Zip Code:

Email:

Best Phone Number:

Best Time to Call:

Number of Persons Age 20-64:

Number of Persons Age 65+:

Number of Persons Age 19 or Under:

Yes

If yes, please explain:

Yes

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other/Unknown

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