Sample FamAsst Beneficiary Application, Allegro Organizational Solutions

We grieve with you in your loss. Please share with us the following information, so that we at “Company Name” may consider how to help you.

** This is a sample application for illustrative purposes only. Please use the application with your group or corporate name.

Applicant Name *

First

Last

Provide the name of the person in the family who represents the family to the group. If the group is a company, this is the employee of the company.

Phone Number *

Please provide more than one, if you have more than one phone number.

Alternate Phone

Email *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please provide your normal address, where damage may have occurred.

Number of People in Home *

Please provide the number of people who normally reside at the address including the applicant

Description of Situation *

Please describe your situation with the following details and others you wish to provide: Describe home damage, items lost/damaged greater than $500 in value, your present living situation, your anticipated date of return to your home, if living away from it. For what would assistance funds be used? Were you insured for losses? What personal loss such as physical or emotional injury has your family experienced?

Applied for FEMA Assistance *

Have you already applied for FEMA assistance?

Covered by Flood Insurance *

If you suffered property damage, were you covered by the National Flood Insurance Program.

Describe Your Recovery Plan

This may be an estimated timeline of recovery goals with dates.

Other Needs

Besides money, what other kinds of help do you need?

Upload Loss or Damage Photo 1

Upload Loss or Damage Photo 2

Upload Loss or Damage Photo 3

If possible, please upload three photos which show your situation.

Verification Person *

First

Last

Please provide the name, phone number and email address of someone in our group/company who can verify the information above.

Verification Email *

Verification Phone *

Person Completing Application

First

Last

If someone assisted in filling out this form, please give their name and phone number.

Phone

To the best of my knowledge and belief, these responses are true, correct, and complete *

I Affirm

*** Pressing the submit button below will NOT submit an application to any Family Assistance Fund. This sample form is for illustrative purposes ONLY. Please use the application with your group or corporate name

If you experience errors submitting a form with attached photos, your corporate firewall may be preventing submission. Please try again from another connection.

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