Sumter LTRG Disaster Assistance Request Form

If you or someone you know has been affected by a disaster in Sumter Co. and need help, please complete this form. An LTRG team member will review your request and contact you as soon as possible. You may complete and return the Long-Term Recovery Assistance Application (PDF Version) or submit your request and documentation via the form below.

Please provide as much detail as possible about your needs – this will help us connect you with the right resources and volunteers. All information submitted is confidential and used only for recovery coordination.

A - Applicant & Contact Information

Full legal name(Required)

Preferred name (optional)

Date of birth(Required)

Phone number(Required)

Email address(Required)

Current Mailing Address(Required)

Street, City, State, Zip

Co-applicant name (if applicable)

Emergency contact name(Required)

Emergency contact relationship(Required)

Emergency contact phone(Required)

B - Household Information

Total number of household members(Required)

Number of children under 18(Required)

Number of adults 65+(Required)

Disabilities, functional needs, or access needs (describe if applicable)

Language preference or interpreter needed?

Current living situation (own home, rental, hotel, shelter, with friends/family, other)(Required)

C - Disaster & Application Information

Disaster/Event name and type(Required)

Incident dates (Start–End)(Required)

FEMA Disaster (DR) number (if known)

FEMA Application Number (if applicable)

Insurance claim number(s)

D - Damaged Property Information

Damaged Property Address (Street, City, State, ZIP, County)(Required)

Is this your primary residence?(Required)

Yes

Dates of occupancy (From–To)(Required)

Type of dwelling (single family, mobile/manufactured, multi-unit, other)(Required)

If renting: landlord/park name and contact

E - Residency & Ownership Verification

Proof of residency(Required)

Select the type of proof being provided (at least one required)

Government-issued ID showing damaged address

Utility bill (dated within 3 months pre-disaster)

Lease, mortgage, or insurance document

Official mail (bank, employer, or government)

School records

Affidavit of residency (if no documents available)

Proof of residency - uploads/attachments(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 3.

Proof of Ownership (if applicable)(Required)

Select the type of proof being provided (at least one required if applicable. If not applicable please select 'Not applicable' below)

Recorded deed or property title

Property tax record

Mortgage statement

Manufactured home title/DMV record

Probate, heirship, or court documentation

Purchase/closing documentation

Not applicable

Proof of ownership - uploads/attachments(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 3.

F - Disaster Impact

Disaster impact(Required)

Select all that apply

Home damaged or destroyed

Displacement

Loss of income/employment

Loss of transportation

Loss of personal documents

Injury or death in household

Other disaster-related impacts

Description of impact(Required)

Provide brief summary of how the disaster affected your household

G - Current Recovery Needs

Basic needs

Select all that apply

Housing repair/rebuild

Rental or utility assistance

Food, clothing, transportation

Medical care or childcare

Financial / documentation needs

Select all that apply

FEMA or insurance assistance

Replacement of vital documents

Budgeting/financial recovery planning

Employment support

Emotional & social support needs

Select all that apply

Counseling or mental health services

Spiritual or peer support

Stress, grief, or trauma support

H - Recovery Goals

Immediate priority #1(Required)

Immediate priority #2(Required)

Immediate priority #3(Required)

Desired long-term recovery outcome(Required)

I - Financial, Insurance & Documentation Summary

(Attach documentation as available; not all items required at intake)

Documentation attached(Required)

Select the type of documentation being provided with this application.

Income documentation (tax returns, pay stubs, benefits)

Bank statements

Insurance claims and adjuster reports

Contractor estimates or repair bids

Receipts for disaster-related expenses

Documentation of lost income

None attached - I will provide this documentation to the LTRG at at later date.

Documentation - uploads/attachments

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 6.

J - Assistance Applications & Case Coordination

Indicate programs applied for or received(Required)

Individual Assistance

SBA Disaster Loan

State or local housing programs

Insurance claims (homeowners/renters/flood/auto)

Nonprofit or community assistance (Red Cross, Salvation Army, etc.)

Not applicable

K - Health & Access Needs (Optional)

Health & access needs (optional)

Medical needs or injuries related to disaster

Medication replacement needs

Disability accommodations required

Other health or safety concerns

L - Additional Household Considerations

Additional household considerations (if applicable)

Senior (60+) household member

Disability or functional needs

Limited English proficiency

Pets in household

Other considerations

N - Authorization & Consent

Authorization & Consent(Required)

I authorize the Long-Term Recovery Group (LTRG) and partner agencies to collect, share, and verify information necessary to coordinate disaster recovery services, including personal, housing, financial, and case-related information. to the privacy policy.

Authorization is voluntary
Valid for up to one (1) year unless revoked
Information is used only for recovery coordination
May be shared only with participating recovery partners

O - Participant Rights

Participant Rights(Required)

Participation is voluntary
Information is protected and used only as permitted by law
Declining consent may limit assistance
This program does not replace medical, legal, or mental health care

I have read, understand and agree to the Participant Rights outlined above.

P - Signatures

Applicant Signature(Required)

Co-Applicant Signature (if applicable)

Unique ID

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Sumter LTRG Disaster Assistance Request Form

A - Applicant & Contact Information

B - Household Information

C - Disaster & Application Information

D - Damaged Property Information

E - Residency & Ownership Verification

F - Disaster Impact

G - Current Recovery Needs

H - Recovery Goals

I - Financial, Insurance & Documentation Summary

J - Assistance Applications & Case Coordination

K - Health & Access Needs (Optional)

L - Additional Household Considerations

N - Authorization & Consent

O - Participant Rights

P - Signatures

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