Disaster Assistance Application

This application takes 30-45 minutes to complete. Please read it completely and carefully.

Jefferson County Long Term Recovery Group (JCLTRG) assists vulnerable individuals and households with unmet needs related to disaster. Our home repair/rebuild programming targets uninsured or underinsured, low income homeowners that meet one or more of the following vulnerabilities:

65 AND OLDER

DISABLED

US VETERANS

SINGLE PARENT HOUSEHOLDS WITH UNDERAGE OR DISABLED CHILDREN

All cases are dependent upon funding availability.

You will be required to provide hard copies of specific supporting documentation in addition to this application. If you need help locating your supporting documents, please call us so we can assist you. Our phone number is: 409-240-0331.

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* 1. Do you live in Jefferson County, Texas?

Yes

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* 2. Do you have unmet needs as a result of storm/disaster impact?

Yes

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* 3. What disasters have you been impacted by?

Hurricane Harvey

Tropical Storm Imelda

2024 Spring Storms (straight line winds/tornado April 2024)

Hurricane Beryl

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* 4. Please check the appropriate choices that apply to your unmet needs as they relate to a recent storm/disaster impact:

Home Repair (outside)

Home Repair (inside)

Furniture/Appliance Replacement

Other (please specify)

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* 5. Head of Household (Full Legal Name):

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* 6. Please provide a reliable phone number(s) for us to contact you:

Phone number 1:

Phone number 2:

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* 7. What is the address of the DISASTER IMPACTED property?

Number/Street

City/State

Zip

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* 8. What is your MAILING address? (if same as above, please skip question)

Number/Street

City/State

Zip

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* 9. Please provide a working email address that you routinely check.

Email 1

Email 2

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* 10. Head of Household Date of Birth:

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* 11. How many individuals live in your household?

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* 12. Please list the name(s) and date(s) of birth for each individual in your household (exclude yourself):

Name / Date of Birth

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* 13. Do you have anyone in your household that is disabled?

Yes

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* 14. Do you have anyone in your household that is a US Veteran?

Yes

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* 15. Are you a single parent with children under the age of 18?

Yes

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* 16. If you receive child support, please list the monthly amount below:

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* 17. Do you OWN or RENT your home?

Own

Rent

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* 18. Which of the following best describes your home:

Site Built Home

Mobile Home

Other

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* 19. Are you employed?

Yes

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* 20. Please provide the total monthly income for each person(s) in your household. Start with yourself: (you will be required to provide copies of supporting documentation)

Person 1:

Person 2:

Person 3:

Person 4:

Person 5:

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* 21. Do any members of your household receive social security, unemployment or disability (SSI) benefits?

Yes

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* 22. Do you have a MORTGAGE on your home? (Do you pay monthly notes to a bank or lender)

Yes

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* 23. What is your monthly mortgage or rent payment?

Mortgage:

Rent:

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* 24. What is your monthly homeowners and/or flood insurance premium?

Homeowners Insurance:

Flood Insurance:

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* 25. What is the amount of your monthly Electric/Natural Gas/Propane expense?

Electric:

Natural Gas:

Propane:

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* 26. What is the amount of your monthly Water/Sewer and Garbage expense?

Water/Sewer (average):

Garbage:

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* 27. What is the amount of your monthly phone/cable/internet expense?

Cell Phone 1:

Cell Phone 2:

Cell Phone 3:

Home Phone:

Internet/Wifi:

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* 28. Please list individual monthly car payment amounts for each household vehicle:

Monthly vehicle payment 1:

Monthly vehicle payment 2:

Monthly vehicle payment 3:

Monthly vehicle payment 4:

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* 29. Please provide the total combined monthly amount paid for vehicle insurance coverage on all household vehicles:

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* 30. Please provide an estimated monthly expense for gasoline:

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* 31. Please provide the total monthly prescription drug expense for all members of the household combined:

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* 32. Please provide total monthly payments for all outstanding loans/credit cards not included in previous categories mentioned above:

Credit Card 1:

Credit Card 2:

Credit Card 3:

Misc Loan 1:

Misc Loan 2:

Misc Loan 3:

Other expense:

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* 33. Please provide the total monthly amount spent by the household on food:

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* 34. If your household receives food stamps/SNAP, please provide that amount here:

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* 35. Please briefly describe the unrepaired damages to your home:

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* 36. Please describe other unmet needs that you need assistance with:

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* 37. Please share any additional information not listed in this application but you feel is important:

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* 38. Do you attest that all information you have provided in this survey is TRUE and CORRECT? (By choosing "yes" you are stating that all information you have provided is factual to the best of your knowledge)

Yes

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* 39. Jefferson County LTRG is a 501c3 nonprofit organization that supports the unmet needs of households impacted by disaster by providing direct services, advocacy or resources. We are not a government agency and do not receive government funding. Because we are working with many client applications, we cannot provide a timeframe for new application processing. Our services are based on available funding. We cannot guarantee that we will be able to fulfill your unmet needs. Your case will be considered in the order it was received and if funding is available. We will do our best to connect you with other organizations or resources that are providing disaster assistance in our community. Have you read and understood the information above? (by checking "Yes" you are attesting that you have read and understand the above information.)

Yes

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* 40. Jefferson County Long Term Recovery Group is a not-for-profit organization. We make it our goal to coordinate, cooperate, and collaborate with local, state and federal partners, and many other organizations that are disaster missioned, to serve our clients in the biggest way possible. Our funding is typically received through local donations, private donations, and grants. The funding we receive is used to purchase construction supplies for case managed, vetted home repair/rebuild projects. We then bring in vetted, trusted volunteer groups from across the state and nation, who provide home repair/rebuild labor at no cost to us or our clients. Disaster recovery is not a fast process. It can take months to complete one project. This is usually dependent on funding and volunteer availability. We will clearly communicate our plan of action with all clients. We will be transparent about our abilities as we move through the process. Have you read and understood the information above? (By checking "Yes" you are attesting that you have read and understand the above information)

Yes

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* 41. Do we have your permission to share your information with other vetted partner organizations that may be providing assistance and/or funding for households impacted by disaster so that they may reach out to you? (If you check "no," you may miss opportunities for disaster assistance. We will never share your information with any organization that is not a trusted community partner.)

Yes

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* 42. Before finalizing and submitting your application please carefully read and record the information below so that you can begin collecting these documents. These documents MUST be submitted to our office after filing your application. CLICK HERE for a printable copy of the required supporting documents.

You are responsible for submitting hard copies of the following supporting documentation to our offices after completing your online application:

- Drivers License or State ID for all person(s) living in the home over the age of 17.
- Income statement(s) including social security and/or disability information and child support if you are a single parent with children
- Bank Statements (LAST 3 MONTHS)
- Utility bills (These must list the damaged address and your name)
- Monthly bills (ALL) including cable/internet/cell phone/car payment/insurance (car/property/health/other) prescriptions, etc.
- Outstanding loan and credit card documentation
- Home Ownership Documents/House Deed
- FEMA award/denial letter (if applicable)
- Insurance award/denial information (if applicable)
- Photos of before/after storm (if applicable)
- Property tax statement showing taxes are current or applicant has a payment arrangement with the county

CLICK HERE for a printable copy of the required supporting documents listed above

Email supporting documentation:
director@JCLTRG.org

Hand-deliver supporting documentation:
Call our offices at 409-240-0331 to set up an appointment to drop off paperwork.

IMPORTANT:
Once your application is complete and you understand what documents need to be provided to us, you may submit your application by clicking the Blue Box below. IT IS IMPORTANT THAT YOU CLICK THE BLUE BOX BELOW.