Department of Emergency Management Primary Residence Damage Assessment

1. Primary Residence Damage Assessment Survey

1 / 4

Please use this Damage Assessment Survey for PRIMARY RESIDENCES only.

Please fill out the survey in its entirety. Incomplete responses will not be included.

*
1. First Name

First Name

*
2. Last Name

Last Name

*
3. Street Address:
Enter the street address of the DAMAGED PROPERTY. To help us with our mapping, use only numbers or letters (no symbols such as #). Use standard postal abbreviations: Rd for road, ST for street, Blvd for boulevard, Hwy for highway, Ave for avenue.

Street Address: Enter the street address of the DAMAGED PROPERTY. To help us with our mapping, use only numbers or letters (no symbols such as #). Use standard postal abbreviations: Rd for road, ST for street, Blvd for boulevard, Hwy for highway, Ave for avenue.

*
4. City:

City:

*
5. Zip Code:
Enter the 5-digit zip code of the DAMAGED PROPERTY (not zip+4).

Zip Code: Enter the 5-digit zip code of the DAMAGED PROPERTY (not zip+4).

6. Occupant Status

Occupant Status

Department of Emergency Management Primary Residence Damage Assessment

1. Primary Residence Damage Assessment Survey

*1. First Name

*2. Last Name

*3. Street Address:Enter the street address of the DAMAGED PROPERTY. To help us with our mapping, use only numbers or letters (no symbols such as #). Use standard postal abbreviations: Rd for road, ST for street, Blvd for boulevard, Hwy for highway, Ave for avenue.