Disaster Fund Assistance Request

Great Plains Annual Conference Disaster Response Ministry - An UMCOR Partner

Head of household post-disaster contact info
*First Name
*Last Name
*Address 1
Address 2
*Number and ages of children in household:
*Number and ages of adults in household:
*Type of Disaster
*Household income:
*Pre-disaster address:
*Applicant was a:
*General circumstances of the family
*Has assistance from other sources been requested? Please answer from whom and what the assistance is:
*Assistance requested from Great Plains Disaster Fund:

You may attach supporting documents below.

Attach supporting documents:

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*Who should the check be made to/sent to:
*Request submitted by:

Please include mailing address and phone number.

*Please check:
United Methodist pastor
Conference disaster response coordinator
Regional disaster response coordinator
Great Plains appointee to LTRC
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