NCSSA Hardship Relief Funds Application

Contact Information

Date of Application ?
First Name
Last Name
Home Address
City
State
Zip
Mobile
Email

Business Information

Associated Storage Business
Business Address
City
State
Zip
Phone
Title

Type of Hardship

Natural Disaster impacted your business or place of employment. Includes Hurricanes, Tornado, Flooding, Lightning, Fire or similar incidents which have caused personal hardship. This does not include damage to businesses or facilities and is not intended to replace lost business income.
Health related incidents to the individual or immediate family member through illness, accident or crime which have caused personal hardship.

Natural Disaster

Date of Incident
Describe Nature of Incident
Describe Personal Hardship
Amount Requested for Individual Emergency (up to $500)
Description of relief needed

Health Related Incidents

Date of Incident
Describe relationship of affected individual to applicant
Describe health related incident or illness
Describe impact on the affected individual for day-to-day activities
Estimated cost on affected individual
What will insurance cover
A member of the NCSSA Hardship Relief Fund Review Team will follow up after receipt of your application.
With your signature, you attest that all responses and comments are true and accurate to your knowledge.
   - denotes required fields