Request for Assistance | Hope Desoto Long Term Recovery Group Inc.

Name *

Email address *

Message or Brief Description of Disaster Impact *

Primary Residence (Address)

Cell / Phone Number

Household Composition

Ownership (own, rent or live with family or friends)

Currently Displaced? (yes or no)

Received or currently Receiving Assistance from *

FEMA
DeSoto Habitat
DeSoto County
State of Florida
All of the above
None of the above

Release of Information: I consent to disclose my information (name, address, phone number, case files, inspection records, amount of assistance, etc.) to any partnering agencies or organizations that are involved in disaster relief and recovery. *

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