Disaster Assistance Request Form

Please use this form to submit a Disaster Assistance Request.

* Indicates required field

Name *

First

Last

Current Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Cellphone *

Alternate Phone Number *

Home Address (if different from Current Mailing Address) *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Please explain how you have been impacted by this disaster *

What specific personal needs do you or your family have that are not currently being met? *

If you are out of work, how can we help you get back to work? (What needs are there? tools, relocations assistance, etc) *

Referred to CIF by *

Employer or Manager Contact Name *

First

Last

Work Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer Phone *

What benefits have you applied for and/or received? *

Submit

If you have been displaced, or have lost your work tools due to the damage caused by a natural disaster, please complete out the form below of click the link to download the form for mailing into us.

Click Here to Download he Disaster Assistance Form

​Disaster Assistance Request Form

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Disaster Assistance Request Form

Home | Disaster Relief | Donate | Supporters | About CIF | News | Testimonials | Gala