County:
City/Town:
Type of dwelling:
Name:
Phone #:
Address:
Do you:
Is this home constructed of:
Do you have a:
Did damage occur in the basement:
Did damage occur at the first floor level:
Was the source of flooding sewer backup:
Depth of flood water in basement:
Is your basement Essential Living Space?:
What kind of Living Space?:
Depth of flood water in first floor level:
How many floor levels does your home have?:
Was there any damage to your foundation?:
If yes, to what extent:
Was there damage to your personal property?:
If yes, what was damaged?:
Do you have homeowners insurance?:
If yes, what is the company name?:
Is your home in a designated floodplain?
Do you have Flood Insurance?
Do you have sewer back-up insurance?
Additional information or directions to damaged property:
This form is NOT an application for any assistance program
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