*1.Please enter your first and last name(Required.)

2.What is your business name?

3.Please enter your email address.

4.Please enter a contact phone number.

5.How was your business affected by the severe storm?

Minimal

Moderate

Extreme/ Severe 

6.Did you experience any loss of the following items? (Please select all that apply)

Crop Loss

Infrastructure  (Roads, fencing, greenhouses, buildings)

Equipment (Irrigation system, electric systems, pumps, etc.)

Ag Use Vehicles (Ranch/Farms Trucks, Tractors)

Livestock

Other

7.Estimate the loss value in US $ from each category.

Crops

Infrastructure

Equipment

Ag Use Vehicles

Livestock

Other

8.If applicable, please enter the approximate crop acres planted.

9.If applicable, please enter the approximate crop acres damaged.