Knights of Columbus Nebraska Jurisdiction
Natural Disaster Relief Request Form


Initial Request Additional Request
Person Requiring Assistance Provide all Applicable Information
Complete Name of Person Requiring Assistance
Physical Address
City
Zip
Mailing Address
City
Zip
Phone Number	Invalid format.
Email	Invalid format.
Council Number (if Knight of Columbus or Widow of)
Catholic	Yes No
Parish (if Catholic)
Date of Loss	Invalid format.
Description of Loss and Immediate Needs if Known
Amount of Insurance or FEMA Assistance Received to Date (if Applicable)
Describe other Assistance Already Received (if Applicable)
Estimate the Total Dollar Ammount of Loss (for Comparison Purposes Only)

Person Requesting Assistance
Complete Name of Person Making Request	A value is required.
Address
City
Zip
Phone Number	Invalid format.
Email	A value is required.Invalid format.
Council Number
Council City
Title in Council (e.g. Member, Grand Knight, etc.)

By checking this box you affirm that all information provided is accurate and if requesting funds on behalf of another, the receiving party is aware of the request. (Required to submit form.)	This is required to submit a request.