Application for Trotwood Disaster Relief Fund Grant
Name:
_________________________________
Date of Birth:
_________________________________
Last 4 of Social Security Number:
_________________________________
Current Address:
_________________________________
_________________________________
Address within Disaster Area:
_________________________________
_________________________________
Expected Address in Trotwood (If
Different Than Above):
_________________________________
_________________________________
Occupation:
_________________________________
Years Living in
Trotwood?:_______________________
_ (Yes or No) _____
Email Address:
________________________________
Telephone Number:
_________________________________
Spouse:
_________________________________
Dependents and Ages (Living With
You):
_________________________________
_________________________________
_________________________________
_________________________________
Amount Requested (No More Than
$1,000):
_________________________________
Submitted F.E.M.A. Application?
(Yes or No) _____
Submitted SBA Application?
(Yes or No) _____
Submitted Ohio EMA Application?
 Application for Trotwood Disaster Relief Fund Grant

Describe how the funds would be used?

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_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Describe how the funds would help you stay or move back to Trotwood?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________
 Application for Trotwood Disaster Relief Fund Grant

Describe the loss and estimated value of property:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Signature: _______________________________ Date:____________________

PLEASE TURN APPLICATION IN AT THE TROTWOOD

GOVERNMENT CENTER 3035 OLIVE ROAD, TROTWOOD, OH 45426.