Foundation Application-Disaster Relief

Name

Contact Information

Phone

Mailing Address

Address

City/Town

State/Province

ZIP/Postal Code

Is this your primary place of residence?

Yes

Are you the property owner?

Yes

Is the property insured?

Yes

Source of Personal Income

List Other Members in Household

Please inlude the age, relatioinship and employer for each household member

List Other Members in Household
	List Other Members in Household	Item weight

more items

Amount of Grant Request

Description of Damage

Please indicate what was lost including when, where and how.

Is the individual or family receiving any other form of assistance or aid for the above stated request?

Yes

If yes, please list funding source(s) and amount

If no, type "n/a"

Are you requesting funds from other source(s)?

Yes

If yes, please list funding source(s) and telephone number(s)

If no, type "n/a"

Please indicate a brief budget for this project

Have you previously applied for funding from the Central Community Foundation?

Yes

Applicant Signature

By signing below, you affirm that the information presented on this application is accurate. (Applications that are not signed will not be processed or considered by The Central Community Foundation board of directors)

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Foundation Application-Disaster Relief