________________________________________________________________________ _____________________
Consent to Release Form
Purpose: By signing this form, the Primary Applicant gives ReBuild NC permission to receive
information about the Primary Applicant from Federal Emergency Management Agency (FEMA), Small
Business Administration (SBA), insurance companies and/or other relevant organizations. The
Program then uses this information to determine the Primary Applicant’s program eligibility.
Instructions: The Primary Applicant should complete this form, providing their full legal name and the
complete address of the damaged property. In order to be valid, this Consent to Release Form must be
signed and dated by the Primary Applicant.
Warning: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for
knowingly and willingly making false or fraudulent statements to any department of the United
I, _______________________________________ currently own the property at:
Primary Applicant Name
_____________________________ ______________________________________________________,
Damaged Property Address
hereby consent to the disclosure of my information collected by FEMA, SBA, insurance companies,
National Flood Insurance Program (NFIP), and/or other organizations to the North Carolina Office of
Recovery and Resiliency (NCORR), the entity that administers the ReBuild NC Homeowner Recovery
The purpose of this disclosure is to assist with the determination of my eligibility and otherwise process
the amount of assistance for the ReBuild NC Homeowner Recovery Program administered by NCORR for
the damaged property located at:
Damaged Property Address
I understand that I have an ongoing duty to inform NCORR of any known or possible assistance received
by any person who resides at the damaged address for the qualifying event (Hurricane Matthew or
Florence). This duty remains even after assistance has been received.
I consent to the following information being disclosed to ReBuild NC:
- Information from third party entities including, but not limited to: inspection report(s), amount o
assistance received, and future assistance to be received.
ReBuild NC is a program of the North Carolina Office of Recovery and Resiliency
Last Updated: April 23, 2020
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- Documentation of amounts paid to me or other owners or on my or their behalf by an insurance
company for homeowner, flood, or other insurance.
- Documentation of all financial assistance provided to me or other owners, received by me or
other owners, or made available to me or other owners for storm recovery assistance and the
purpose of that assistance (e.g., rental assistance, food and gas, home repairs).
- Ownership, tax, lien, mortgage, property, and income records.
- Additional information necessary as identified by ReBuild NC.
To provide goods and services including case management, the coordination of recovery efforts among
agencies and non-profits, and the prevention of duplication of services, I consent that the above
information may be disclosed to the above organizations and others that may be identified by ReBuild
NC. All the information contained in this Consent to Release Form is true and complete to the best of my
knowledge and belief.
Primary Applicant Signature Date
ReBuild NC is a program of the North Carolina Office of Recovery and Resiliency
Last Updated: April 23, 2020
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