Contact Info
20
%
Application Request
First / Last name
Phone number
Email address
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Impact Of Home
40
%
Please select the state your primary residence is located in.
Please select
GA
KY
Please select
Please select the county your primary residence is located in.
Graves County
Other:
Please select the county your primary residence is located in.
Coffee County
Other:
Was your home affected by the tornado on December 10, 2021?
Yes
No
Was your home affected by Hurricane Helene in 2024?
Yes
No
What was/is the address of the home that was affected by the disaster?
Do you rent or own this property?
Rent
Own
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Employment Info
60
%
Are you currently employed?
Yes
No
Who is your employer?
Location of Employment
City / State
Do you receive any other type of income?
EX: Pension, Social Security, Disability, etc.
Yes
No
Please tell us what type of other income you receive.
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Family Info
80
%
Adults residing in your home:
Please select
1
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4
Please select
Children residing in your home:
Please select
0
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4
5
6
Please select
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Assistance
100
%
Are you currently receiving any other assistance due to the specified disaster?
Yes
No
Who are you receiving assistance from?
Verification
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