AMO Membership Assistance Program Relief Benefits Application "*" indicates required fields Applicant InformationName* First Middle Last Current Phone*Cell PhoneEmail* Current Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Book # / Applic # Damage DescriptionType of LOSS* Date of LOSS* MM slash DD slash YYYY Address of Damaged Property* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Residence Do you rent or own your home? Rent Own Is this your primary residence? Yes No Do you have any disaster related essential need for food, clothing, or shelter? Yes No Home Damages?* Yes No Estimated Value of Home Damage LOSS*Home Damages Pictures* Drop files here or Select files Accepted file types: jpg, png, gif, pdf, Max. file size: 50 MB. If Yes, please provide a detailed description of the home damages below.Personal Property Damages?* Yes No Estimated Value of Property Damage LOSS*Personal Property Damages Pictures* Drop files here or Select files Accepted file types: jpg, png, gif, pdf, Max. file size: 50 MB. If Yes, please provide a detailed description of the personal property damages below.Have you submitted an insurance claim?* Yes No If Yes, please attach a copy.Accepted file types: pdf, doc, jpg, png, Max. file size: 50 MB.If No, please explain why not.Please list all persons living in home at time of disaster(1) Name (1) Relationship (1) Age(1) DependantYesNo(2) Name (2) Relationship (2) Age(2) DependantYesNo(3) Name (3) Relationship (3) Age(3) DependantYesNo(4) Name (4) Relationship (4) Age(4) DependantYesNo(5) Name (5) Relationship (5) Age(5) DependantYesNo(6) Name (6) Relationship (6) Age(6) DependantYesNoCAPTCHA
