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Q&A Forum



Contact Information
Date of Application	?
First Name
Last Name
Home Address

City
State
Zip
Mobile
Email

Business Information
Associated Storage Business
Business Address

City
State
Zip
Phone
Title

Type of Hardship
Business impacted by Nature/Accident. Includes Hurricanes, Tornado, Flooding, Lightning, Fire or similar incidents causing major damage to the facilities.
Health related incidents to the individual or immediate family member through illness, accident or crime.


Business Impacted by Nature/Accident
Date of Incident	?
Describe nature of incident
Describe impact on the facilities
Estimated cost of the incident
What will Insurance cover

Health Related Incidents
Date of Incident
Describe relationship of affected individual to applicant
Describe health related incident or illness
Describe impact on the affected individual for day-to-day activities
Estimated cost on affected individual
What will insurance cover

Please complete and return the attached W-9 Form.

A member of the NCSSA Hardship Relief Fund Review Team will follow up after receipt of your application.

With your signature, you attest that all responses and comments are true and accurate to your knowledge.

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