This form is designed to collect information so County officials can get a better understanding of the impacts to Wahkiakum County.  This information can also help the County and possibly it's residents potentially qualify for disaster assistance. ** There is no guarantee of funding 

*1.Your Contact information(Required.)

Name *

Company

Address *

Address 2

City/Town *

State/Province *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code *

Country

Email Address

Phone Number *

*2.Have you suffered damage from the Winter Storm and or flooding during the December 2021 and January 2022 storms?(Required.)

Yes

No

*3.Is the damage you are reporting within Wahkiakum County WA?

*** THIS FORM IS DESIGNED TO COLLECT INITIAL AND BASIC DAMAGE ASSESSMENT INFORMATION.  YOU WILL BE CONTACTED FOR MORE INFORMATION IN THE COMING DAYS.

(Required.)

Yes

No

*4.Did the damage arise from the Winter Storm and/or Flooding during December 2021 to January 2022?(Required.)

Yes

No

*5.What is the physical address of the damage you are reporting?  *** If you are reporting damage for multiple addresses please complete a new form for each address.(Required.)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

*6.Please briefly describe the related damage.(Required.)

7.Picture 1/20 - Please add up to 20 pictures to help us get a good idea of the damage.

Please add up to 20 pictures to help us get a good idea of the damage.

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8.Picture 2/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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9.Picture 3/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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10.Picture 4/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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11.Picture 5/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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12.Picture 6/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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26.Picture 20/20 - Please add up to 20 pictures to help us get a good idea of the damage.

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