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CURRENT RESOURCE AMOUNTS CASH ON HAND AMOUNT

SOURCE

CHECKING ACCOUNT(S) AMOUNT

SOURCE

SAVINGS ACCOUNT(S) CHRISTMAS CLUBS, VACATION CLUBS AMOUNT

SOURCE

OTHER RESOURCES AMOUNT

SOURCE

DISASTER EXPENSES AMOUNTS Please list the disaster expenses that you have paid or expect to pay out-of-pocket during the disaster benefit period. If you have received or anticipate receiving reimbursement for an expense, please list only the net expense. DO NOT INCLUDE EXPENSES THAT WERE PAID OR EXPECTED TO BE PAID BY SOMEONE OUTSIDE YOUR HOUSEHOLD.

EXPENSE TYPE AMOUNT SOURCE HOME OR BUSINESS REPAIRS

TEMPORARY SHELTER

EVACUATION EXPENSES

MEDICAL EXPENSES DUE TO PERSONAL INJURY

DISASTER-DAMAGE VEHICLE EXPENSES

FUEL FOR PRIMARY HEATING SOURCE

CLEAN-UP ITEMS EXPENSES

STORAGE EXPENSES

EXPENSES RELATED TO REPLACING ITEMS, SUCH AS CLOTHING, APPLIANCES, TOOLS, AND EDUCATIONAL MATERIALS

DISASTER-RELATED PET BOARDING

DISASTER-RELATED FUNERAL EXPENSES

HOME OR BUSINESS PROPERTY PROTECTION

OTHER (EXPLAIN)