FFWF Disaster Relief Form

YOUR NAME *

First

Last

YOUR HOME ADDRESS *

Address Line 1

City

State

Zip Code

TEMPORARY ADDRESS (if displaced from home)

Address Line 1

Address Line 2

City

State

Zip Code

YOUR PHONE NUMBER *

YOUR EMAIL ADDRESS *

UNION MEMBERSHIP *

NAME OF UNION MEMBER *

First

Last

UNION MEMBER'S RELATIONSHIP TO YOU *

Please describe union member's relationship to you

UNION and LOCAL NUMBER *

UNION CONTACT *

Please provide the name and phone number of a contact at your (or your family member’s) local union.

CHECK ALL THE LOSSES THAT APPLY *

Assistance is limited to a maximum of or equivalent to $500 once every 12 months.

Describe HOME loss and monetary value

Describe VEHICLE loss and monetary value

Describe OUTBUILDINGS loss and monetary value

Describe LIVESTOCK loss and monetary value

Describe OTHER loss and monetary value

NUMBER OF PEOPLE IN YOUR HOUSEHOLD *

Please explain your hardship in detail and prioritize your greatest needs *

Signature *

Today's date *