Assistance Application – North Texas REALTORS® in Action Foundation

Name*

First Last

Current Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Occupation*

Date of Birth*

Primary Residence Address*

Same as above

Street Address Address Line 2 City State ZIP Code

Please upload a copy of your drivers license or other government ID with application*

Please indicate if you rent or own your primary residence.*

Rent
Own

List the names and ages of persons who you claim as dependents on your income tax*

Name	Age

Enter none if you don't have any dependents.

Give a description of your immediate needs (i.e. food, clothing, money, lodging, transportation, etc.)*

Describe the damage or financial loss relating to your primary residence. Give a full description of the damages to the structure, other improvements, and personal property in the residence.*

Please describe the amount of time (if any) that you were displaced from the home and the financial loss you incurred to obtain alternative living accommodations*

Are your losses covered by an insurance policy?*

Yes
No

Please describe the policies and status of any claim:*

Company*

Name of agent or company representative*

Agent’s or representative’s phone*

Agent’s or representative’s address*

Street Address Address Line 2 City State ZIP Code

Amount of deductible*

Amount of claim*

Amount paid or agreed to be paid to you on the claim*

Did you claim additional living expense reimbursement?*

Yes
No

Status of claim*

Total UNINSURED loss to my primary residence*

Please provide any other comments about the coverage or claims you wish to be considered in this application

Have you applied to other relief funds?*

Yes
No

List the funds to which you applied and describe the status of the applications*

Please detail any financial assistance you received or will be receiving from other sources*

Approximate annual household income (you may be asked to provide additional financial information)*

Please describe how you plan to use any funds received from the North Texas REALTORS in Action Foundation to meet your immediate needs due to displacement from or damage to your primary residence*

You must submit one or more of the following documents to show proof of damage to your primary residence. Please check to indicate you are attaching one or more of the following*

Pictures of damages
Auto Insurance Policy - If you are seeking financial assistance for car repairs, you must upload a proof of your current auto insurance
Copies of written claims, settlement proceeds, or claim status reports
Copies of repair estimates from contractors
Copy of property information from appraisal district
Other

Upload supporting documents*

Drop files here or

*

I attest that I have answered all questions truthfully and to the best of my ability.

Signature*

First Last

Date*