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2. The Emergency Elderly & Disabled Assistance Program provides vital support to Homestead’s most vulnerable residents during a declared State of Emergency. Authorized by the City Council under Resolution No. R2024-08-100, this program ensures that essential emergency supplies like sandbags, ice, and water are delivered directly to elderly and disabled individuals who cannot access distribution sites. The program is operated in coordination with city staff and volunteers, guaranteeing swift response and care during times of need.

   Please complete the form below to apply. Your application will be reviewed, and upon verification, you will be added to the delivery list. The assistance program is exclusively for residents who live within City of Homestead limits. If you do not receive a utility bill from the City of Homestead, you are most likely not eligible to participate.

6. Applicant Information
8. First Name*
9. Last Name*
11. Date of Birth*
    Date of Birth
13. Address 1*
15. Address 2
17. City*
18. State*
19. Zip*
21. Phone Number*

    Primary Contact Number

22. Email Address*

    Primary Email Address

24. Emergency Contact Information
26. Emergency Contact Name*

    First & Last Name

28. Relationship*
30. Phone Number*
34. Household Information
36. Number of Adults in Household*

    Type Number

37. Number of Children in Household*

    Type Number

41. Driver's License Verification
43. Upload a copy of your Driver's License or State ID*

    This is required to verify your residency within the City of Homestead

47. Acknowledgment
49. I certify that the information provided is accurate and that I am a resident of the City of Homestead.*
    -- Select One --YesNo
53. Signature
55. Digital Signature*

    Type Full Name

56. Date of Submission*
    Date of Submission
60. Form Submission and Review

    Once submitted, your application will be routed to the City of Homestead's Emergency Management Department for verification. Upon successful verification, you will be added to the Emergency Elderly and Disabled Disaster Assistance Program list. 

64. Promotion and Communication

    Stay informed about important updates, including this program and other City of Homestead news, by following us on social media and staying connected through our digital print announcements. You can easily access all our social media platforms, newsletters, and more in one convenient place by clicking here for a link to our social media accounts at https://www.homesteadfl.gov/socials. Stay connected and never miss an update!

66. Contact Information

    For any questions or assistance with the application process, please contact Emergency Management at emergencymanagement@homesteadfl.gov 

Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field