PLEASE ONLY ONE RESPONSE PER HOUSEHOLD

* 1. First name

* 2. Last name

* 3. Primary phone number

* 4. Address of flooded residence

* 5. Date residence flooded

Date
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* 6. Residence type

* 7. Level of Damage (Please download FEMA guidelines to select the best choice)

* 8. Do you have flood insurance

* 9. Will you need debris removal assistance from the county?

* 10. Describe your damage

* 11. Describe any agricultural-related damage (if applicable)

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