This information is vital to distribution of relief funds and should be completed and returned as soon as possible. As the president of your local union, please review this form carefully before submitting.

Required Field Invalid Field


LOCAL UNION INFORMATION
President First Name Required
President Last Name Required
President's Phone Number Required

Local Number Required
Unit Number Required
Address Required

City Required
State/Province Required
Postal Code Required
Total Hourly Employees Required
Total Union Members Required
EMPLOYER INFORMATION
Employer Name Required
Employer Phone Required
Address Required

City Required
State/Province Required
Postal Code Required
DAMAGE INFORMATION

Please read the following information carefully. When finished, enter the total number of members affected per each level of the scale.

Total loss of home and personal items including dislocation.

Major wind and/or water damage to home and significant damage to personal items.

Significant roof loss, minor home flooding including basements and attached garages or numerous trees down but most repairs requiring more labor than materials.

Minimal resident damage, trees down, damage to fencing or non-resident structures but with the home mostly intact.

REVIEW & SIGN

The above information is accurate to the best of my knowledge.

Signature Required