Name *

First Name

Last Name

What amount will your employees be eligible to receive in Evacuation/Displacement relief? *

This is a one-time grant following a Federally-declared disaster.

$1,000

$750

$500

If the employee receives a grant from the Evacuation/Displacement Program and they are eligible for additional disaster assistance, would you like us to deduct that amount from any future grants? *

YES

NO