State Individual Assistance Application Español The North Carolina Individual Assistance program helps uninsured or underinsured families impacted by declared State and Federal disasters. If you have insurance, file your loss with your insurance company immediately. Eligibility for the IA program requires that you apply for a disaster loan through the U.S. Small Business Administration (SBA) at 1-800-659-2955 or disasterloanassistance.sba.gov If your loan request is denied by SBA, you become eligible for State IA grant assistance by completing and signing the application below. Indicates required field Applicant Information Name First Name Middle Initial Last Name Date Damaged Property Address Damaged Property Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Current Address Current Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Mailing Address (if applicable) Mailing Address (if applicable) City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Alternate Phone County - Select -AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYancey Email Disaster name / event Date of Loss Are you displaced? Yes No Did you experience a home or business loss? Home Business Are you the homeowner? Yes No Is the property insured? Yes No Did you submit a disaster loan application to the Small Business Administration (SBA)? Yes No Are you a renter? Yes No Please describe the disaster impact: DestroyedAffectedHabitableUnhabitable Acknowledgement, Disclaimer and Signature I, the applicant, understand and acknowledge that my grant application to the State of North Carolina for funds under its Individual Assistance (IA) program in no way guarantees receipt of funds. I understand the IA program is a supplemental program to assist with making homes safe, sanitary, and functional. I further understand the program is not intended to rebuild or fully cover all home recovery needs. I acknowledge that funding consideration for this program is contingent upon documented application to the Small Business Administration (SBA) and subsequent loan denial due to a failed income test. I further acknowledge that refusing to accept an approved Small Business Administration loan automatically disqualifies me from being eligible for IA supplemental assistance. Furthermore, I understand that the State of North Carolina’s IA program may not duplicate any benefits received from insurance or any other sources. I hereby consent to the disclosure of the information collected by North Carolina Emergency Management (NCEM) to complete disaster application. By typing my full name in the signature box below, I agree to the conditions above and certify that the information I am providing is true and accurate. Privacy Statement Signature
State Individual Assistance Application Español The North Carolina Individual Assistance program helps uninsured or underinsured families impacted by declared State and Federal disasters. If you have insurance, file your loss with your insurance company immediately. Eligibility for the IA program requires that you apply for a disaster loan through the U.S. Small Business Administration (SBA) at 1-800-659-2955 or disasterloanassistance.sba.gov If your loan request is denied by SBA, you become eligible for State IA grant assistance by completing and signing the application below. Indicates required field Applicant Information Name First Name Middle Initial Last Name Date Damaged Property Address Damaged Property Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Current Address Current Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Mailing Address (if applicable) Mailing Address (if applicable) City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Alternate Phone County - Select -AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYancey Email Disaster name / event Date of Loss Are you displaced? Yes No Did you experience a home or business loss? Home Business Are you the homeowner? Yes No Is the property insured? Yes No Did you submit a disaster loan application to the Small Business Administration (SBA)? Yes No Are you a renter? Yes No Please describe the disaster impact: DestroyedAffectedHabitableUnhabitable Acknowledgement, Disclaimer and Signature I, the applicant, understand and acknowledge that my grant application to the State of North Carolina for funds under its Individual Assistance (IA) program in no way guarantees receipt of funds. I understand the IA program is a supplemental program to assist with making homes safe, sanitary, and functional. I further understand the program is not intended to rebuild or fully cover all home recovery needs. I acknowledge that funding consideration for this program is contingent upon documented application to the Small Business Administration (SBA) and subsequent loan denial due to a failed income test. I further acknowledge that refusing to accept an approved Small Business Administration loan automatically disqualifies me from being eligible for IA supplemental assistance. Furthermore, I understand that the State of North Carolina’s IA program may not duplicate any benefits received from insurance or any other sources. I hereby consent to the disclosure of the information collected by North Carolina Emergency Management (NCEM) to complete disaster application. By typing my full name in the signature box below, I agree to the conditions above and certify that the information I am providing is true and accurate. Privacy Statement Signature
