Please use this form to submit a Disaster Assistance Request. 

Name:*
Current Mailing Address:*
Cell Phone:*
-
Alternate Phone Number:*
-
E-mail:*
Please explain how you have been impacted by this disaster.*
What specific personal needs do you or your family have that are not currently being met?*
If you are out of work, how can we help you get back to work? (What needs are there? tools, relocations assistance, etc)*
Referred to CIF by:*
Employer or Manager Contact Name:*
Employer Company Name: *
Work Shipping Address:*
Employer Phone:*
-
What benefits have you applied for and/or received? *
Word Verification:

If you have been displaced, or have lost your work tools due to the damage caused by a natural disaster, please complete out the form below of click the link to download the form for mailing into us.

AssistanceForm