Disaster Relief Request Form In order to better assist those who are affected by natural disasters in Eastern Oklahoma, this form will give us the information needed to serve to those in need. LoveChangingLives First Name * Last Name * Home Address * Please list the address of the residence affected by disaster. Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * County * Please list the county of the residence affected by disaster. Phone 1 * Please list two phone numbers where you can be reached. Phone 2 * E-mail * Emergency Contact First Name * Emergency Contact Last Name * Emergency Contact Phone * Details of Disaster * Other Agencies * Please list the names of other agencies who have already assisted you and what assistance those agencies have provided. Other Information Please list any other information that may help us serve you better.