Interview Application Date MM DD YYYY Applicant Nickname * Number of adults in household * Number of children in household * Ages of children Do you own or rent the home impacted by the flood? * Own Rent Declared Disaster? * Yes No Provide an overview of the needs of the applicant. * (Examples: "Applicant is 3 months overdue on rent." "Applicant faced wage losses due to catastrophic disaster." "Applicant lost their furnace in flooding." What is at stake? * (Example: "Will enter winter with inadequate housing." ) Assistance requested: * Housing Insecurity Heat Insecurity Utility Insecurity (non-heat) Vehicle Loan/Repair Lost Wages Groceries Mental Health Child Care Declared Disaster Other- describe below If other was selected, please describe: Estimated level of assistance needed Modest Moderate Significant Thank you for submitting your request. The Flood Relief Committee meets weekly and will respond to your request as soon as possible.