SCTE Foundation Disaster Relief Fund Grant Request Form for Individual Support

The SCTE Foundation Disaster Relief Fund supports individuals, as well as broader community relief efforts, where disasters occur.

Please send supporting ( Insurance claim and deductible amount, Home Repair receipts for goods and services) documentation to [email protected]

Name: *

First

Last

If you or someone in your household is a Cable Industry Employee please provide name of your Employer: 

Email Address: *

Best phone number to reach you: *

Home Address: *

City: *

State: *

Zip: *

Other Household Members? *

• Yes
• No

If yes, please list up to 5 Household Members

Name, Age, Relationship

Description and location of event that resulted your disaster loss: *

Date of event: *

YYYY-MM-DD

Please describe the nature of your loss and the circumstances surrounding your request for assistance: *

What is the estimated dollar amount of the loss you suffered that is not covered by insurance or other forms of assistance?

e.g. payments received from governmental agencies, charitable organizations, friends and family, etc.

Type of Hardship: *

• Temporary housing
• Home repair / rebuilding costs
• Replacement furniture
• Replacement clothing
• Meal cost replacement
• Miscellaneous toiletries, supplies etc.

Reimbursement Requested for Each Type of Hardship *

By checking the box, I certify that the information provide in this grant request form is true and correct. I acknowledge and permit the SCTE Foundation to verify all information. Any intentional misrepresentation of information contained in the form will result in forfeiting this grant request now and in the future.

• Authorization

Direct Deposit if a grant is awarded, please select “Yes, I want direct deposit” if you would like your relief assistance electronically deposited into your bank account.

• Yes, I want direct deposit

Your bank routing and account numbers will be collected following the notification.

Share Your Story – Do you give the SCTE Foundation permission to contact you in order to share your story?  *

• Yes
• No

Submit

The maximum permitted grant amount per individual / household is $5,000.
Please be aware that you will be required to provide receipts for the costs that you are asking to be covered as a result of this assistance request.