If you are an individual impacted by the explosion on April 10, 2019, please fill out this form to be considered for assistance.
Please do not submit any personal or confidential information like social security numbers or medical records.
The deadline to apply is June 3rd, 2019.
If you have questions or trouble with the form, please email email@example.com
If you are a business impacted by the explosion, there will be more information coming soon from OEWD.
By submitting this form, I hereby certify that the information provided in this claim form is true and accurate to the best of my knowledge. Submission of this form does not constitute a waiver of any legal rights. Further, I understand that false statements made in connection with this claim will be forwarded to the appropriate law enforcement agencies for possible investigation.
I herby agree that no member of the Board of the Committee, nor any officer or employee of Upstream Works Collaborative acting on behalf of the Board or the Committee, shall be personally liable for any action, determination or interpretation taken or made with respect to the fund.