Dr. Theodore A. Atlas Foundation, Teddy Atlas

Hurrican Sandy Assistance Relief Applications

What sticker color was your house classified? Red Yellow Green
Name			Last
Address	Apt#
City	State Zip Code
Do you have Children?	Yes No	If yes how many?		What is your Annual or Monthly Gross Income?
Home	Rent Own	Marital Status		Applicant's Age
Home	Rent Own	Marital Status		Spouse's Age
Have you applied to Fema?	Yes No	If yes what is your ID# ?
Desired Assistance (Please indicate what your priority needs are.)