Individual Disaster Relief Application

Applicant Name*

First Last

If you are applying on behalf of the applicant, please list your name.

First Last

Relationship to applicant:

Home Address*

Street Address City State ZIP Code

Phone*

Email*

About Your Credit Union

Credit Union Name*

What is your role at the above credit union?*

CEO
Employee
Board Member
Volunteer

Length of employment/relationship with the above credit union (in years)*

About the Disaster's Impact

Please describe the extent of your loss or damages to your primary residence (including estimated dollar value).*

Include loss of home, structural damage, personal belongings, auto, etc.

Have you been displaced from your home because of the disaster?*

Yes
No

How many people (including yourself) live in your household?*

What is your status as an occupant in your household?*

Owner
Renter
Other (live with family, friends, etc)

If you are or were experiencing temporary displacement, please share about your living arrangements. Please provide a temporary address if you are not residing in your primary residence.

Will any damages be covered under insurance? If yes, please provide general amounts that will be covered for your above mentioned expenses.*

Total amount requested for disaster relief funds.*

Please enter a number from 0 to 1500.

Please let us know what method you prefer to receive your disaster relief grant if approved.*

Send check to my home address
Send check to my temporary address
Send check to my credit union
Send electronic fund transfer to my credit union*

*If selecting electronic fund transfer to your credit union, please verify that your credit union is offering this option.

Have you previously received disaster relief funds from GoWest?

Yes
No

Is anyone else in your household an employee or volunteer for a credit union?

Yes
No

Please indicate which credit union and share any relevant details.

Consent*

I acknowledge that all of the information provided on this form is true and all funds that I may receive will be used to aid me or my household with damages caused by severe weather.

Consent*

I give permission to reach out to my credit union to verify my relationship and status with the credit union is accurate.

Thank you for your application. Would you be willing to be contacted to share a message of gratitude with the donors supporting our disaster relief fund?

Yes
No

Upload any relevant files or photos

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Max. file size: 80 MB, Max. files: 3.