SCTE Foundation Disaster Relief Fund Grant Request Form

Other Household Members? *

Yes

No

Do you have homeowners or renters insurance? *

Yes

No

If so, does it cover temporary living expenses?

Yes

No

Have you lost your income as a result of this disaster? *

Yes

No

Type of Hardship: *

Temporary housing

Replacement Clothing

Replacement Food

Replacement Furniture

Misc. toiletries supplies etc.

Immediate cash assistance

Homeowner/Renter Insurance Deductible (requires documentation of insurance claim and deductible amount)

Home Repairs not covered by insurance (requires receipts for goods and services)

Authorization *

I certify that the information provide in this grant request form is true and correct. My signature acknowledges and permits the SCTE Foundation to verify all information. Any intentional misrepresentation of information contained in the form will result in forfeiting this grant request now and in the future.

Direct Deposit If a grant is awarded, please select the “Yes, I want direct deposit” radio button if you would like your relief assistance electronically deposited into your bank account. Your bank routing and account numbers will be collected following the notification

Yes I want direct deposit

Share Your Story - Do you give the SCTE Foundation permission to contact you in order to share your story? *

Yes

No