Disaster Relief Request Form

In order to better assist those who are affected by natural disasters in Eastern Oklahoma, this form will give us the information needed to serve to those in need.

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First Name *

Last Name *

Home Address *

Please list the address of the residence affected by disaster.

Address 1 *

Address 2

City *

State *

ZIP code *

County *

Please list the county of the residence affected by disaster.

Phone 1 *

Please list two phone numbers where you can be reached.

Phone 2 *

E-mail *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone *

Details of Disaster *

Other Agencies *

Please list the names of other agencies who have already assisted you and what assistance those agencies have provided.

Other Information

Please list any other information that may help us serve you better.

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Disaster Relief Request Form