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Disaster Relief Application
Please provide the following information:
First Name
Last Name
Phone Number:
Email:
Please provide your address (where the relief check should be sent):
The address below is my:
choose one
Permanent Address
Temporary Address
Street Address Line 1:
Street Address Line 2:
City:
State:
Zipcode:
Personal Information:
For payments to individuals, the IRS does require us to collect the Social Security number for report and audit purposes.
Social Security Number:
What is your current situation?
Acknowledgement Required:
choose one
Yes
I understand that that through the submission of this application, my personal information will be shared with members of the Disaster Relief Committee.
Attestation Required:
choose one
I confirm that I am currently an NSA member in good standing.
My NSA membership has lapsed.
E-Signature Required:
- denotes required fields
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