Form 90-69 Application / Registration for Disaster Assistance

UbPAKIMkN I ur HUMtLANU bbLUKI 1 Y
FEDERAL EMERGENCY MANAGEMENT AGENCY

1

APPLICATIONIREGlSTRATlON FOR DISASTER ASSISTANCE

I Name o f Appl~cant(last, first, M I )

2 Language

OK#

Exp February 28,2W7
(see reverse side)

APP. D A T E

4 Applicant Soclal Secur~tyN o

3 Date of B ~ r t h

6 Damaged Phone #

LOSS
Date

U.M.H. NO.IbW-UUU2

7 Current Phone #

5 Emall

AlternatdCell Phone #

Note
8 Damaged Property Address

I

Srreet

Apt501

C~ty

9 M r l l n g Address
1
Street
Apt5Ot
1 Cnty
bame as Damaged Address
10 Cause ofDamage.
Flood
Sewer Backup
Seepage
n
n
n
n
n
Earthquake
Fire
UIceISnow
U ~ a i l ~ a i n i WDriven
in
Rain
U~ornado~ind
U Power SurgeLightening U Other
I 1 Home Damage:
YES
NO
Unknown
12. Personal Prapeny Damage
YES
NO
13. Utilities Out
I
I
14. Current L o c a t i o n : n
Primary Home
HoteVMotel
FamilyiFriends
Mass Shelter
Other
15. Residence Type.
Travel Trailer
Mobile Home
Home-Singlwlluplex
Apt.
OCondofbwnhouse
Boat

I

U

U

16 Primary Res~dence-

U

UYES U

-

U

0

U

U

'

'

NO

U Own

17. D o you

-

'

q

18. Is your home accessible

22 Other Expenses:
Chainsaw

Generator

1I ZIP

YES

U YES

Count'

L9"0

n

U ~ o , due to mandatory evacuation
No. due to disaster
20. Disaster Related Expenses (for uninsured or underinsured expenses)
Expense Type
YES
NO
I F YES and have insurance: InsuranceCompany Name
Medical

Insurance Company Name

Wet/Dry Vac

n

I

=Ip

u

q Other

U Rent

1

19. HomeRersonal Property Insurance:
Insurance Type

ISme I

1 State

Dehumidifier

Air Purifier

23. Emergency Needs:

Food

Shelter

Clothing

24. Special Needs D i d you, your spouse, or any dependents have help or support doing things like walking, seeing, hearing, or taking care of yourself before the disaster and have you lost that help or support because of the
disaster?
Yes
No
wheelchair,'
walker.
cane,
lift,
bath chair,
personal care anendant, etc
I f Yes: (Select all that apply)
Mobility, such as:

q

I1

'I

q

q

q

(Select all that apply)

I

n
U

q

-

Co~nitivJMentalHealth. such as: Personal care attendant. etc
Hearing or speech, such as: hearing aid, sign language interpreter, TDDIITY, text messaging
andlor other accessible communication device
as:

First Name

Last Name

I

Other

n Virion, such Glasses, white cane, service animal, Braille. or other accessible communication device, magnifier
25. Occupants living i n primary residence at time o f disaster:
MI

Relationship

Social Security No. (Applicant First please)

Dependent?
YES
NO

Age

26 BUSINESS DAMAGES.

I

SelfEmployment is primary income?

I

YES

I

NO

I

I

OwnRepresent a business or rental property affected by disaster?

29. Electronic Funds Transfer.

27. Number of claimed dependents

Institution Name
28. Combined family pre-disaster gross income

1Weekly

nhome

-

$-

qMonlhly U Semi-monthly

OB~-weekly

Quarterly

Lehsed

-

ADIOYN type.

ahecking

I

YES

uWS
q
OSavings

NO

I

NO

Routi.

NO.

(9 digits)

Acwunt N o

q Yearly
I

30 Comments

3 1. FEMA Representative:

7
I

FEMA Form 90-69. DEC 05

REPLACES ALL PREVIOUS EDITIONS.