Office Use Only
RR#
Souris Valley Long Term Recovery
Rebuild and Retain Application
Attention Applicants:
Distribution will be considered for Safe, Sanitary, Secure, and Essential Living space. Applicants must
have owned their flooded home prior to the June 2011 flood and must plan to reside in their home for at
least 2 years.
Homeowners who have received buyout letters are ineligible for this grant.
Families must fall between 100-300% of Annual Federal Poverty Guidelines.
MUST Mail application to:
Souris Valley Long Term Recovery Committee
c/o Souris Valley United Way
15 2nd Ave SW, Suite 102
Minot, ND 58701
Phone: 701.838.1338
email: svuwflood@srt.com
Name of Applicant (print):
___________________________________________________________________________________
Date of application (MM/DD/YYYY): _____/_____/_____
Date of Birth (MM/DD/YYYY):
FEMA #: _________________________
_____/_____/______
Photo ID: _______________________________
Pre-Flood Address
Ward County
____ Yes
____ No
Did applicant formerly
 Home (Single Family Dwelling)
own ?
Number of persons residing in pre-flood household:
 Mobile Home / Trailer
Adults:_______ Dependent Children:_______
Current Address
Current Mailing
(if different from above)
Applicant’s Phone #
Alternate phone #
E-Mail Address
Does applicant currently reside at flooded home? ____ Yes
____ No
Number of persons residing in current household: Adults:______ Dependent Children:______
Household’s annual income (line 22 from Federal 2011 Income Tax Form) $__________________
Applicant or other flood-affected household member has a documented disability. ____ Yes
Resources Received:
____ No
Date received
FEMA
$___________
___/__/____
SBA Loan
$___________
___/__/____
BND Loan
$___________
___/__/____
Flood Insurance
$___________
___/__/____
Minot Area Recovery Fund $_____________
___/__/____
Souris River Basin Unmet Needs Committee $_____________
___/__/____
Please check only one category for assistance.
___________ Receipt Reimbursements (Receipts Required at time of Interview)
(Accepted for essential building materials on main floor may include water heater or furnace).
___________ Direct Vendor Payment (for Essential Building Materials for Main Floor)
I verify that I have been affected by the 2011Spring Flood in the following way(s):
I was displaced from my home which I owned.
I suffered substantial or complete loss or damage to my home which I owned.
I suffered the loss of household income.
I resided in a mandatory evacuation zone.
I sold my flooded home, which I owned.
I purchased and will reside permanently in a location other than my flooded home.
I have rebuilt my flooded home and will sell or use it as rental property.
I certify and declare to the best of my knowledge and belief that the information I have provided is true,
accurate, and complete, and that I lack the financial resources necessary to complete my recovery from
Spring 2011 flooding.
Home Owner
Signature:
Print:
Date:
Print::
Date:
Home Owner
Signature:
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CONSENT AND RELEASE
I,
, hereby authorize the Souris Valley Long Term Recovery
Committee to share any of my information in its possession, including but not limited to my name, address, other
personal information and the type of assistance I am receiving with other disaster relief and voluntary organizations.
If you wish to limit this release to specific information, please specify the information that may be released.
___________________________________________________________________________________________
I understand that I may revoke this consent at anytime by contacting Souris Valley Long Term Recovery Committee
except when action has already been taken to obtain and/or release such information to organizations providing
resources. My signature on this release indicates that I have read the above, or had it read to me, and that I
understand the terms and conditions. I have also had the opportunity to ask any questions. I am also signing this
release on behalf of my children that are under the age of eighteen (18).
Signature Home Owner
Date
Signature Home Owner
Date
CONFIDENTIALITY AGREEMENT
Any information provided by the client(s) to the Organization’s Staff or Volunteers is to be kept in the strictest of
confidence. None of the information exchanged about donor individuals, donor organizations, or client cases will be
discussed outside of the official interview and decision-making process of the Organization, except as authorized
above.
___________________________________________________________________________________________
Signature
Souris Valley Long Term Recovery Representative
Date
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