"*" indicates required fields SEIU 2015 Disaster Relief Fund Application for ReimbursementFull Legal Name of Qualifying Member(s): (List everyone in household who may qualify)*Have you paid your membership dues at least six months out of the last 24 months?* Yes No Additional Eligibility Information if Applicable (please explain any unique circumstance)Your Current Mailing Street Address* Your Current Mailing City* Your Current Mailing Zip Code* Was your address at time of fire loss different than the above? Yes Your Previous Address Your Previous City* Your Previous Zip Code* Type of Assistance Requested* Temporary Housing Assistance ($1,000 max) Other needs reimbursement ($2,000 max)(please describe) Please describe your reimbursement requestAssistance RequestedTemporary Housing Costs Other Disaster-Related Loss Direct Vendor Payments Cash Advance Request Total Requested ($3,000 max individuals; $4,000 max for two member household) Your Contact Phone and EmailYour Cell Phone* Your Email* Rolodex Number Provider ID Please attach formal documentation for all expenses for which you are requesting reimbursement. Staff will contact you via email or phone with 14 days to confirm receipt of your application. Incomplete or inaccurate applications will not be processed.Upload your formal documentation Drop files here or Select files Accepted file types: jpg, png, pdf, tiff, Max. file size: 5 MB.