CANDIDATE'S PERSONAL INFORMATION
OBRF CANDIDATE'S CIRCUMSTANCE / STATEMENT OF NEED
HOUSEHOLD INCOME INFORMATION (Include ALL)
OTHER INCOME / BENEFITS
HOUSEHOLD EXPENSE INFORMATION
Attach Your Proof of Address (such as Driver's License, Current Utility Bill, etc.) and Proof of Medical Diagnosis (if applicable).
Accepted file types: jpg, pdf, Max. file size: 20 MB.
Drop files here or
NOTE: This Form of Need is used by the Outer Banks Relief Foundation, Inc. and its Board of Directors to determine the level of need and appropriate assistance. The Foundation, while sensitive to the confidential personal, financial and medical information you are providing in your request for assistance, must conduct an investigation and cannot and does not guarantee the confidentiality of the information you provide, or which may be provided. By requesting to be considered for assistance, you knowingly and voluntarily waive any and all privileges and confidentiality requirements whether under State or Federal law, and agree to hold the Foundation, and those who provide information to the Foundation, harmless from any and all liability for any disclosures of information provided to or obtained by the Foundation.
I have read the above statement and agree with Outer Banks Relief Foundation, Inc.’s confidentiality policy and in consideration of their acceptance and consideration of my Form of Need, agree to be bound by the terms thereof. I also certify that the information I have provided in my Form of Need and any other information provided to the Outer Banks Relief Foundation is true and correct to the best of my knowledge. Furthermore, I agree that if I am awarded relief funding and I do not use those funds within 6 months of the award date, the balance is forfeited and will become Relief Foundation unrestricted funds. I may apply again for relief funding if circumstances make me eligible.