ONE PURPOSE OF THE STEELWORKERS CHARITABLE AND EDUCATIONAL ORGANIZATION IS TO ASSIST STEELWORKER MEMBERS WHO HAVE SUSTAINED FINANCIAL LOSS AS A RESULT OF NATURAL DISASTERS. INFORMATION PROVIDED WILL BE KEPT CONFIDENTIAL. DUE TO THE AVAILABILITY OF FUNDS, THERE IS NO GUARANTEE THAT ALL REQUESTS WILL BE GRANTED.

Required Field Invalid Field DENOTES A REQUIRED OR INVALID FIELD. CLICK EACH ICON FOR MORE INFORMATION.

MEMBER INFORMATION

District USW District Required

Local Number Local Number Required

First Name First Name Required

Last Name Last Name Required

Phone Number Phone Number Required Invalid Phone Number

Secondary/Work Phone Number Invalid Phone Number

Marital Status USW District Required

# of Dependents (incl Spouse) Number of Dependents Required Invalid Number

Last 4-digits Social Security Number 4-Digit SSN Required Invalid Number

Address Address Required

Address 2

City City Required

State/Province State/Province Required

Postal Code Postal Code Required Invalid Postal Code.

Were You Displaced From Your Home? Answer Required

If Displaced, What Is Your Temporary Address?

EMPLOYMENT INFORMATION

Employer Name Employer Name Required

Address Address Required

Address 2

City City Required

State/Province State/Province Required

Postal Code Postal Code Required Invalid Postal Code.

Last Date Worked Last Date Worked Required Invalid Date

Are You Currently Working? Answer Required

Do You Have Salary Continuance? Answer Required

Is Your Spouse Employed? Answer Required

Where Is Your Spouse Employed?

DAMAGE INFORMATION

Please provide detail for the items for which you need our assistance. Please do your best to approximate the damage. Estimates can be in USD ($) or percentage based on the Total Estimated Value.

PROPERTY #1

Type of Property Property Type Required

Total Estimated Value (USD) Total Value Required Invalid Amount

Estimate Type Estimate Type Required

Estimated Damage Damage Estimate Required Invalid Amount or Percentage

Amount Reimbursed By Insurance Amount Reimbursed Required Invalid Amount

PROPERTY #2

Type of Property

Total Estimated Value (USD) Invalid Amount

Estimate Type

Estimated Damage Invalid Amount

Amount Reimbursed By Insurance Invalid Amount

PROPERTY #3

Type of Property

Total Estimated Value (USD) Invalid Amount

Estimate Type

Estimated Damage Invalid Amount

Amount Reimbursed By Insurance Invalid Amount

PROPERTY #4

Type of Property

Total Estimated Value (USD) Invalid Amount

Estimate Type

Estimated Damage Invalid Amount

Amount Reimbursed By Insurance Invalid Amount

EMERGENCY INFORMATION

Did You Apply For Federal Aid?

If Yes, What Was The Result?

Do You Have Other Emergency Needs?

REVIEW & SIGN

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

Signature (Enter Your First & Last Name) Signature Required Signature Mismatch

I Agree & Have Reviewed My Assessment