Disaster Relief

At this time, we are only accepting disaster relief applications from Jack’s employees directly impacted by the recent hurricane.

For additional resources, visit:

HUD Disaster Resources
Financial Assistance after Disaster
Disaster Assistance

Apply for financial assistance to help you recover from losses and damages directly resulting from recent severe storms in your area.

"*" indicates required fields

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Dropbox Links

Applicant's Information

Applicant's Name*

First Last

Email*

Mobile/ Cell Phone

Address*

Street Address City State ZIP Code

Employment Info

Jack's Store #*

Employee Number*

Hourly Pay Rate*

Average hours worked per week*

How long have you been part of the Jack's Family?*

Household Info

Including yourself, how many people live in your household?*

Please enter a number greater than or equal to 1.

Household Members*

Including yourself, please list names, ages and relationships of all individual living with you at time of disaster. To add additional rows, click the “+” icon to the right of the row.

Name

Age

Relationship to you

Household Monthly Income*

How much income does your household have in a typical month? Sources of income include salary/wages, Social Security, Disability, Food Stamps, TANF, WIC, Child Support Payments, Section 8 Rental Vouchers, etc.

Gov't Issued Photo ID

If available, please upload government issued photo ID for yourself and any household members age 18 or older.

Max. file size: 32 MB.

Needs Assessment

Do you and your family need immediate/emergency shelter?*

Yes

Where are you currently sleeping and bathing?*

Please be specific.

Do you have lost/damaged property or belongings as direct result of storm?*

Yes

Property Damages*

Please list damages to property/belongings sustained as direct result of storm along with estimated (best guess is fine) cost to repair/replace.

Item Damaged

Estimated Cost to Repair/ Replace

Will insurance help cover any of these repairs/replacements?*

Yes, all should be covered

Yes, but only some

No insurance coverage

Property Damage Photos/ Estimates

If you have photos of the damages or estimates for repair and/or replacement, you may upload them now.

Drop files here or

Max. file size: 32 MB.

Mortgage/ Rent Information*

What is your monthly rent/ mortgage payment? (If you do not have monthly mortgage or rent payment please enter “0”)

Please enter a number from 0 to 3000.

Landlord/ Property Manager or Lender

Contact Person or Company Name

Address

Contact information for landlord, property manager or lender.

Street Address Address Line 2 City State ZIP Code

Phone

Utilities*

On average how much do you spend each month on electric, water, trash, and natural gas?

Do you have your most recent billing statements?

Yes

Not Sure

Utility Billing Statements

If you have copies of your most recent billing statements, you may upload them here.

Drop files here or

Max. file size: 32 MB, Max. files: 4.

Immediate Needs

In an average month, how much does your household spend on the each of the following?

Groceries/ Hygiene ($)

Cleaning/ Laundry ($)

Basic Clothing ($)

Other Essentials (e.g. prescriptions, diapers, etc.)

Long Term Housing Assistance*

Do you need assistance to get back into long-term housing as a direct result of the storms?

Yes

Long Term Housing Needs*

Please provide a short explanation of your specific needs and associated costs.

Additional comments

If there is any other information directly related to losses you have suffered or the needs you now have as a direct result of the storm, please let us know.

Certification and Consent

Please read and accept the following Certification and Concent policy.*

(1) I certify that to my knowledge I am following all laws, statutes and regulations restricting U.S. persons from dealing with any individuals, entities or groups who are subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers.
(2) I consent to the processing of my personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Jack’s Family Fund. (3) I further consent to the transfer of the contents of this Application to the Fund located in Birmingham, Alabama, USA, the Jack’s Family Fund Administrator, the Jack’s Family Fund Board of Directors or Allocation Committee Members.
(4) I further certify to the Fund that the information contained in this Application is true and correct.
(5) By applying for a grant from the Fund, I agree to provide copies of the following materials if requested by the Fund: verification of the emergency hardship and financial need, photo identification for myself or any individual to whom assistance grant is made payable, household budget information, income/benefits verification, copies of past due utility bills, rent/mortgage statements, funeral invoice, medical bills, etc.

I agree

Signature