DRRA

Providing Real Resources to Rebuild

Impact Confirmation Form

The information you provide below will remain confidential.

We require it to assure that people who have not been affected by the Los Angeles fires can not abuse the generosity of others.

Emailrequired

Full Namerequired

Phone Numberrequired

Address of Impacted Propertyrequired

How are you associated with the impacted property?required

Will you be able to provide proof of ownership/tenancy?required

YesNo

Was this your primary residence?required

YesNo

What is the current status of your home?required

Number of household members displacedrequired

Are you looking to rebuild?required

YesNo

What kind of assistance do you need? (Select all that apply)required

Insurance Statusrequired

Do you confirm that the above information is truthful to the best of your knowledge?required

YesNo

Captcha (required)

Please avoid sharing sensitive data such as passwords or credit card info in this form. This is not a secure login or billing page to share that data.

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