Disaster Recovery Intake

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TO start the eligibility process for aid fill out the form below

County of Residence*

First name*

Last name*

Are you a US citizen*

Yes

No

Email*

Cell Phone*

Alternate Phone Number

Address (you are currently staying at)*

City*

State*

Zip*

Is the address you are currently staying at the one in need of repair/rebuild?*

Yes

No

Number of adults in home*

Number of children in home*

Do you own the home or are you renting?*

Home

Renter

Service needed (select all that apply)*

Home Repair

Muck Out

New Home

Business Related

FEMA Application Approved or Denied?*

Approved

Denied

Are you receiving other assistance?*

Yes

No

FILE UPLOADER INSTRUCTIONS PLEASE READ!

Below are file up-loaders. You can attach only documents or pictures to them. To continue processing your application we will need you to upload at least 3 files which are:

A government issued photo ID matching your information
The FEMA letter you have received

*You may only upload one file each to the buttons below*

1. Upload your government issued photo id here:*

2. Upload your letter from FEMA here:*

Who filled out this form? *

910-375-3088

admin@emerge4unity.org

emerge4unity.org

Emerge Ministries

PO Box 299

Beulaville, NC 28518

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