Disaster Assistance Service Application

Hurricane/Disaster Assistance Application

Catholic Charities, Diocese of St. Petersburg, Fl
date for dow

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

:HourMinutesAM/PM Option
Throughout this application there are agreements that require your signature, acknowledgment, and acceptance. These are:
- Electronic Signature Agreement and Consent to Service
- HIPAA Notice OF Privacy Practices
- Rights & Responsibilities Agreement
These documents will be available to read as you progress through the application. Please read these carefully.

Please note that services are only available to Florida residents of Citrus, Hernando, Hillsborough, Pasco, and Pinellas Counties.
Applications are only accepted each Tuesday

from 8AM – 5PM.

Please book mark this site and check back then.
We have reached the maximum submissions for today.

So we can provide adequate attention to each applicant, we limit submissions.

Please book mark this site and check back on the next Tuesday.

This application process checks for duplicate submissions.

If you or another member of your household completes an application it will be automatically rejected by our system.

Save yourself time and effort by not completing multiple applications.
Enter and confirm your email address where you will receive an acknowledgement and any communication from us:

Confirmation Emailexample@example.com

Social Security Number
Are you the head of your household?
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Your county of residence:
As noted on the first page of this application, this service is not provided to residents in other counties.

Please correct your entry or cancel your application.
Mobile or Preferred Phone Number
Provide a phone number where we can reach youFormat: (000) 000-0000.
Alternate Phone Number
OPTIONALFormat: (000) 000-0000.

Count of persons in your household by age, including yourself:
# aged under 18
OPTIONAL
# aged 18-64
Enter 0 if none
# aged 65 and over
OPTIONAL
The total number of household members you have entered must be equal to or more than 1

Coordination of Benefits

Your answers will not effect or reduce any services provided by Catholic Charities, this information is strictly used for coordination of benefits with other providers.
Have you or any member of your household applied for funds or assistance for these same or similar needs elsewhere?
Application status
Name of organization you applied to:
Amount of funds or value of goods you have received or have been pledged:
Enter a dollar amount. If none, enter 0.
Date you applied

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate