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The following form allows you to post a request for assistance that will reach government and not-for-profit organizations that can help you FREE OF CHARGE. We only share information with organizations that can assist you. This information is not sold or shared with solicitors. No affiliate or representative of our organization will ever ask for money or send you a bill. Notify HCRN immediately if this happens

When filling out this form, fill it out with the damaged property information. If you wish to be contacted at another address or phone number, do so where specified in the form.

Date: 2008-05-12
First Name: County: (for Indiana)
Last Name:
Address
City State ZIP

The following information is used to contact you directly regarding this request. In the event that you are staying in a hotel, home of a friend, or temporary shelter please list that here.

Address Same as Above
Enter New Address

Contact person at the cleanup site:
Phone number
Best time to call and setup appointment
Is the contact over 18 years of age? Yes   No
 

FEMA Registration #
Have you signed a FEMA release form? No     Yes
FEMA release allows us to share your information with other agencies that are distributing help or relief

If you did not sign the form, may we send you one? No     Yes
Fax # to send form to:   or   email

If you are requesting assistance with your home, please tell us which applies:
I own the home or mortgage is in my name
I rent the home or apartment
I do not live there, but I am custodian or I am the legally responsible party for property
I own the home, but it is not my primary residence (or was not at time of disaster)
Do you have insurance on the property * Yes   No
*(NOTE: Having insurance does not imply that you cannot receive assistance)
Will you sign a liability waiver to have work performed on the property? No   Yes
What is the damage to your property?
 

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