dhsem logo STATE OF ALASKA
Department of Military and Veteran Affairs
Division of Homeland Security and Emergency Management
DISASTER GRANT APPLICATION
DISCLOSURE STATEMENT

Authority: Authority to collect information for your disaster assistance application comes from Alaska Statute 26.23. Eligibility determinations are based on the State of Alaska Administrative Codes 6AAC 94.200 thru 6AAC 94.380 and 6AAC 94.900.

Eligibility to apply: Any resident with primary residence, transportation, and/or personal property damages. Any resident with medical/dental/funeral expenses as a direct result of the declared disaster. Person who is listed as the Applicant in this application will be the one receiving the grant funds.

Information Disclosure: Giving this information is voluntary; however, failure to give us the information may result in a delay or rejection of your request for disaster assistance. If other Government Assistance Programs (I.e. Small Business Administration) are available, applicants may be required to apply for them prior to receiving funds from the State Of Alaska Disaster Grant Programs. Information will be given to agencies from which you are seeking assistance. It may also be shared with insurers of your damaged property and with other disaster assistance providers to ensure you receive all possible benefits and to check for duplication. Federal Declaration: If a Federal Disaster is declared then this State application may be held in abatement and applicants may be requested to file an application with the Federal Emergency Management Agency (FEMA) and SBA.

Non-Discrimination Statement: State law requires disaster assistance be given in a fair and impartial manner, without discrimination on the grounds of race, color, religion, nationality, sex, age, handicap, or economic status. If you feel you have been denied assistance for one of these reasons, or if you have been discriminated against in any way, immediately contact the State of Alaska Division of Homeland Security And Emergency Management.

(Fields marked with are required for successful submission of application)
1. Legal Name of Applicant: (Last, First MI)
2: Preferred Name (Name you go by):
Title:
Mr. Ms.
Are you a Veteran?
Yes No
3. State, Federal or Tribal ID #:
4. Home (or Contact) Phone #:
5. Work Phone #:
6. Cell and/or Message Phone #:
7. E-Mail Address:
8. Date of Application:
9. Date Damage Occurred:
10. Date of Birth:
11. Borough/REAA:
12. Current Mailing:
Apt / Lot #:
City:
State:
Zip:
13. Damaged Property Address:
Apt / Lot #:
City:
State:
Zip:
14. Directions to Damaged Property (include any special instructions or comments)
15. Names of all persons living in
the home at time of disaster:
(First Last)
Relationship to Applicant:
Age: (17, 18, 19 etc.)
Sex:
16. Special Considerations:
  Yes No    Disability: Do you or your spouse meet the Social Security definition of a disability? You may obtain a copy of this definition form from your local DHS&EM representative.

  Yes No    Special Accomodations: If you or any member of your household require(s) accomodation to allow for a disability, please explain the type of accomodation required on a "Reasonable Accommodation Request" form. You may request this form from your local DHS&EM representative.

  Yes No    Guardianship: Are you under the care of a payee, a conservator or guardian? A copy of a court order is required with the application.
     Caregiver Name: Phone:

  Yes No    Translator or Special Assistance: Do you need assistance with translation into your language or filling out/collecting documentation?

  Yes No    Animal Assistance (Pets, Service Animals, Sled Dog Team, or Other): Do you have needs regarding animals in your home or on your property?

17. Total number of dependents claimed (include applicant)
Pre-disaster family gross income: $ per Month Year
Post-disaster family gross income: $ per Month Year
18a. Do you own a business? No Yes    Name of business:
18b. Was it damaged by the disaster? No Yes (if yes ask your Individual Assistance Officer for other possible assistance referral).
18c. Was the business run out of the damaged property? No Yes If yes which room is the business ran from?
19. Any Unearned income? No Yes (check all that apply)
Social Security Social Security Disability Other:
20. Insurance information: (Mark all types of insurance, regardless of the cause of damage)
I have insurance
I have NO insurance (skip to #22)
I have: Homeowners Business Renters Vehicle Flood (NFIP) Earthquake Other
I am filing claim for: Home Business Renters Vehicle Flood (NFIP) Earthquake Other
My insurance benefits have: covered all damage been insufficient been delayed days     Other
21. Home Insurance Company:
Home Ins. Policy #:
Other (Transport/Life/Renters/etc.) Insurance Company:
Other Ins. Policy #:
22a. Have you applied for and/or been provided with any disaster assistance by another source?
No Yes (list below)

Result of Request:
I did not qualify for the assistance.
I qualified, but the assistance received does not meet the total necessary expense or need.
I am not receiving temporary housing assistance from another source (local government, volunteer or other).
I have not received a determination.

22b. Have you received, or do you expect to receive, any donations?
No Yes (check all that apply) Clothes Appliances Building supplies Other:
23. Do you have disaster-related urgent needs? No Yes (check all that apply below)
Food Clothing Shelter Transportation Medicine Other (specify):
24. Was your Primary Residence affected by the disaster? Yes No (if no, answer #25 then skip to #29)
A primary residence is the one that you live in for more than 6 months a year or in which you have just moved into (prior to disaster) as your primary home.
25. Other damaged property?: No Yes (check type) Secondary Residence Fish Camp Business Other property
26. Were you living there at the time of the disaster? Yes No 27.  Are you living there now? Yes (Skip to #29) No
28. Where are you living now? Family/Friends Hotel Rental Mass Shelter Other
29. Damaged Property Type    House   Apartment/Multi-family Building   Mobile Home   Other:
Approx Sq Ft:    # Floors:    # Bedrooms:    # Bathrooms # Kitchens # Living Rooms
31. Owner/Renter Is there disaster-related imminent danger to your home? (e.g. undermining, landslide) Yes (list under #41) No
32. Owner/Renter Do repairs need to be made so that you can live there safely? Yes (list under #41) No
33. Owner/Renter Are you incurring any relocating expenses that are disaster-related? Yes (list under #51) No
34. Owner/Renter Has financial hardship from the disaster led to your eviction or dispossession? Yes (list under #51) No
35. Renter: Owner requires us to move because their primary residence is unusable and they need a place to live. Yes (list under #51) No
36. Owner: Have you already spent money to repair your home's disaster damages? Yes (list under #41) No
37. Did you own, rent, or live rent free at your primary residence before the disaster? Own Rent Live Rent Free
38. Do you have adequate rent-free housing accommodations? Yes No
39. If you are a Renter and may need to relocate answer the following questions:
How much was your rent before the disaster? Per Month: $ How much is your rent now per month? $
Without disaster assistance, can you afford the rent? Yes No (If no, explain in the “Statement of Needs” section on this application)
40. If you are a Homeowner:
A. Did you purchase your home from a local Housing Authority (i.e. AVCP, IRHA, BSRHA, etc) Yes; if yes, which one? No
B. Did you have a house payment on the damaged property before the disaster? Yes; if yes, how much per month? $ No
C. Are you still making house payments for the damaged property? Yes; if yes, how much per month? $ No
D. Are you currently renting due to the disaster? Yes; if yes, how much per month? $ No
E. Without disaster assistance, can you afford the rent? Yes No; (If no, why not?)
F. Do you own any other residence besides the damaged/destroyed residence? Yes; if yes, where? No
G. Does this additional property meet your family needs for temporary/permanent housing? Yes No; if no, why?
H. Do you have a plan for permanent housing (renting, new purchase, repairing damaged property, etc.) Yes No
I. Have you started getting contractors to look at your house for cost estimates? Yes No

If you answered yes to question I, list the estimated timeframe and costs.
If you answered no to question I, explain the reason why not.

J. Describe what needs to be done to your home before you are able to move back in:

In Property Damage Section list the descriptions of the following; Imminent Danger to Home, Access Issues, Damaged Utilities, Need/Completed Repairs, or anything else you think is important for us to know about your immediate disaster-related needs.

41. PRIMARY RESIDENCE DAMAGES:
42. Do you have damages to your Personal Property? Yes No (Skip to #45)
43. Did you have damages to your tools? Yes No
Are these tools required for your job? Yes No N/A

In Personal Property Damage section list next to each item whether damages occurred at Primary Residence / Secondary Residence / Fish Camp / Business. Include boat motors. Must provide proof of ownership and insurance; some items may require model or serial numbers before eligibility can be determined.

44. PERSONAL PROPERTY DAMAGES:
45. Do you have damages to your Transportation? Yes No (Skip to #49)
46. Do you own other drivable forms of transportation that can fulfill the same needs as that of the damaged vehicle? Yes No
47. (if yes to #45) Type of vehicle damaged? Car/Truck Snowmachine Boat ATV Other
Damaged Vehicle Make
Model
Serial Number
year
Vehicle Insured
Proof of Ownership
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
48. TRANSPORTATION DAMAGES:
49. Do you have Medical / Dental / Funeral disaster caused losses not covered by insurance?
Medical Dental Funeral No loss

In Medical/Dental/Funeral section list disaster-related medical and dental needs. Claims must be verified by appropriate health care provider. Use additional sheets as necessary.

50. MEDICAL/DENTAL/FUNERAL EXPENSES:
51. Statement Of Need: (please give a detailed description of how the disaster has affected you and why you need assistance).:


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