Disaster Relief Grant Application

Credit Union Name*

Credit Union Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name*

First Last

Title or role at credit union*

Phone*

Email*

About the Disaster's Impact

Please describe any structural damage to your credit union branch(es) or buildings.*

Have your staff been displaced from their working environments due to the disaster?*

Please select the types of support you are planning to use disaster relief funds for.*

Please add any additional details about the extent of your loss and your needs at this time.

Total funds requested for disaster relief.*

Please enter a number from 0 to 1500.00.

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

Please let us know if you are interested in our help connecting you to other credit unions and any other ways we can support you during this time.

Upload any relevant files or photos

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