GA Wildfire Disaster Recovery Intake

County of Residence

First name

Last name

Are you a US citizen

Yes

No

Email

Cell Phone

Alternate Phone Number

Secondary Contact First Name

Secondary Contact Last Name

Secondary Contact Email

Secondary Contact Phone

Secondary Contact Relationship

Address (you are currently staying at)

City

State

Zip

Is the house here a mobile home?

Yes

No

Is the address you are currently staying at the one damaged by the disaster?

Yes

No

Number of adults in home

Number of children in home

Is anyone in your home older than 60?

Yes

No

Do you own the home or are you renting?

Home

Renter

Do you own the land or are you renting?

Land Owner

Renter

How long do you expect to need temporary housing?

Has your income been effected by the disaster?

Yes

No

Are you currently employed?

Yes

No

Will you be able to contribute financially to the cost of your temporary housing?

Yes

No

Are you a veteran?

Yes

No

Are you a first responder?

Yes

No

Are you receiving other assistance?

Yes

No

Do you attend church?

Yes

No

(The next questions help us ensure appropriate placement and compliance with program requirements.)

Have you had any prior involvement with the criminal justice system that resulted in a conviction, which may impose restrictions on your presence around minors, schools, or similar environments?

Yes

No

FILE UPLOADER INSTRUCTIONS PLEASE READ!

You may only upload documents or images using the file uploaders below. To continue processing your intake, please provide:

• A government-issued photo ID that matches the information above

• Proof of occupancy (such as a utility bill, lease agreement, or property tax document)

Upload your government issued photo id here:

Upload a document that proves occupancy at the damaged location here:

In 500 words or less please tell us your story and how the disaster has impacted you and your family.

Who completed this form?

Client

Case Manager

To start the eligibility process for assistance with the Georgia Wildfires fill out the form below