Property Repair Requests

FEMA NUMBER *

You must have a FEMA NUMBER or your application is not complete.

HEAD OF HOUSEHOLD *

First

Middle

Last

Date of Birth of Head of Household *

Social Security Number *

Spouse

First

Middle

Last

Date of Birth - Spouse

Social Security Number - Spouse

Email *

Must have access to this email account.

Primary Phone Number *

Must have access to this phone number.

Secondary Phone Number

Only for emergencies

Is the Head of Household a veteran? *

Yes
No
Unknown

How many people live in the household?

Selected Value: 1

List the full names of each person living in the household and their relationship to the Head of Household applying for assistance.

QUESTIONS REGARDING DAMAGED PROPERTY

The address in question must have been damaged from either Hurricane Laura or Delta in 2020. Address must also be in one of the five parishes that make up Southwest Louisiana.

Damaged Property Address must be residential and in a Southwest Louisiana parish. *

Address Line 1

City

State

Zip Code

What parish is this address in? *

Is this residence a *

Is this your primary place of residence? *

Yes
No

Do you rent or own? *

Rent
Own

Was this housing subsidized by

HUD/SECTION 8
HUD/FHA
OTHER
None

Landlord's Name

Landlord's Phone Number

Name of Mortgage Holder

Phone Number of Mortgage Holder

Has FEMA inspected the property? *

Yes
No

Amount Expected from FEMA

Amount Received from FEMA

Did you apply for an SBA Loan? *

Yes
No

Amount Qualified for through SBA

Amount Accepted from SBA

CURRENT LIVING ARRANGEMENTS

What is your living arrangement today? *

Are you currently living in FEMA housing? *

Yes
No

Address

Address Line 1

City

State

Zip Code

Please explain where you are staying

We are a Charity Tracker Participating Agency

Requesting assistance with repairs through this form authorizes United Way of Southwest Louisiana and Catholic Charities, as Charity Tracker Participating Agencies, to look through a shared, computerized record keeping system that captures information about people experiencing a need for emergency services. If you have received assistance from any agency below, add the amount and/or what you received.

American Red Cross

Catholic Charities of SWLA

The Salvation Army

United Way of Southwest Louisiana

Other churches or organizations. Please list their name and amount or item received.

EMPLOYMENT & INCOME VERIFICATION

Employment *

Name of Employer

Employer's Phone Number

Amount of Income *

Interval *

Per hour
Weekly
Bi-weekly
Monthly

GOVERNMENT BENEFITS

Do you currently receive government assistance? (receiving disability is government assistance) *

Yes
No
Have applied but haven't heard yet

Check all assistance received or applied for:

WHAT ASSISTANCE ARE YOU ASKING FOR?

To expedite the review process, requests will have to have support documents listed below for each item checked. *

Other services not listed above

CONTRACTOR OR SKILLED LABOR EXPENSES

Click or drag files to this area to upload. You can upload up to 4 files.

FOR ASSISTANCE WITH EXPENSES FOR CONTRACTORS OR SKILLED LABORERS, PLEASE SUBMIT THREE (3) BIDS (OR EVIDENCE THAT AN EFFORT TO SECURE THREE BIDS HAS BEEN MADE)

FURNITURE, APPLIANCES, BUILDING SUPPLIES

Click or drag a file to this area to upload.

REQUESTS FOR THE PURCHASE OF ITEMS (FURNITURE, APPLIANCES, EQUIPMENT, BUILDING MATERIALS, ETC) OR COSTS FOR SERVICES MUST INCLUDE A WRITTEN ESTIMATE/INVOICE OF THE ITEMS FROM THREE (3) VENDORS (OR EVIDENCE THAT AN EFFORT TO SECURE THREE BIDS HAS BEEN MADE)

UTILITY ASSISTANCE

Click or drag a file to this area to upload.

REQUEST FOR UTILITY ASSISTANCE (DEPOSITS OR MONTHLY COSTS FOR SERVICE) SHOULD INCLUDE DOCUMENTATION FROM THE UTILITY COMPANY.

RELEASE OF CONSENT

On behalf of my household named above, the undersigned, authorize the Federal Emergency Management Agency (FEMA), the Louisiana Housing Corporation (LHC) and Louisiana Office of Community Development, the Coordinated Assistance Network (CAN) to disclose personally identifiable information and/or confidential information relating to the potential financial or other forms of assistance needed for my household, arising from the major disasters declared as: Disaster Flooding FEMA DR-4277. It is given to obtain and/or provide assistance I need as a result of these declared disasters to:

Please check all of the following to apply for assistance. *

Any nonprofit organization that is participating in a FEMA or state recognized Long Term Recovery Committee (LTRC) for FEMA DR-4277.
The State of Louisiana, through the Louisiana Housing Corporation (LHC), the Louisiana Disaster Housing Task Force (LDHTF) and to any agent, state or federal agency, designated to receive information relevant to my household request for any disaster support, including housing relief programs, currently or hereafter available as the result of Hurricanes Laura and Delta.
United Way of Southwest Louisiana
SWLA VOAD

For the purpose of ensuring that: Benefits are not duplicated and appropriate referrals for possible and/or potential services provided by other state, nonprofit, and/or faith-based organizations can be made on my behalf.

CONSENT TO DISCLOSE CONFIDENTIAL INFORMATION

BY SIGNING THIS DOCUMENT I AM GIVING PERMISSION TO SWLA VOAD TO DISCLOSE PERSONALLY IDENTIFIABLE INFORMATION WITH OTHER AGENCIES AS IT PERTAINS TO MY ELIGIBILITY AND ASSISTANCE DURING THE TIME OF DISASTER.

TYPE FULL NAME *

By typing your name and hitting submit you are authorizing all of the above.

Date *