form_disaster_relief

Government of St. Kitts and Nevis Disaster Relief Assistance Form

Important: An incomplete application will not be considered for approval.

1. Name and alias(es) in full: _________________________________________________________ _____

2. A present address where you can be contacted: ________________________________________ _____

    _______________________________________________________________________________ _____

3. Best time to be contacted: __________________________________________________________ _____

4. Telephone number where you can be contacted (if you do not have one, you must list a friend, relative or

other telephone contact where you may be reached): ___________________________________________

5. Address of damaged property (street name, house number, etc.):

   _____________________________________________________________________________________

6. Date of Birth: ________________________      7. Nationality: __________________________________

8. Name of Employer: ____________________________________________________________________

9. Address of Employer: ___________________________________________________________________

10. Telephone of Employer: ________________________     11. Best time to be contacted: ____________

12. Applicant's annual income: _____________________________________________________________

13. Total annual income to household: _______________________________________________________

14. Please give a brief description of the extent of damage: ______________________________________

     ___________________________________________________________________________________

     ___________________________________________________________________________________

15. Is the damaged property your usual place of residence? _______________Yes   _____________    No

16. If yes, list all persons who residence at the damaged premises (you must list all to be considered for approval):

        Name                                          Age        Relationship        Annual                 Occupation
                                                                                                 Income
a.    __________________________    _____     ____________     ____________     _______________

b.    __________________________    _____     ____________     ____________     ________________

c.    __________________________    _____     ____________     ____________     ________________

d.    __________________________    _____     ____________     ____________     ________________

e.    __________________________    _____     ____________     ____________     ________________

      If more than five persons, please attach list to this application.

17. Do you own the damaged property?   ______________   Yes   __________________ No

18. If no.

       A.   Give the name and address of the owner: ____________________________________________

      ___________________________________________________________________________________

      B.    Do you pay rent?   ____ Yes   ____ No. If yes, what is your monthly rent payment? ________

19. Is the property insured?   ___________Yes   _____________ No

20. Are you receiving, other assistance for the immediate reconstruction? _________ Yes ________ No

21. If yes, please specify assistance: _______________________________________________________

     ___________________________________________________________________________________

Important: Any false information indicated on this application will result in ineligibility.

I hereby certify that to the best of my knowledge, the information given above is completely, true and accurate.

__________________________________                     ________________
Signature of Applicant                                                 Date

Please note: An estimate must be attached to this application detailing the cost of repairing damage to the property indicated. The estimate should include a detailed listing of material requirements and the associated cost. The estimated cost of labour should also be included. Financial income information is required for relief assistance.

This programme is administered for the St. Kitts and Nevis Government by the National Emergency Management Agency under the auspices of the Sub-Committee for Relief and Supplies Distribution.

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FOR OFFICE USE:

Date received: _______________________ Initials: _________________

Estimate Included: ____________________ Yes    _________________ No

Disaster Relief Assistance Form