PLEASE ONLY ONE RESPONSE PER HOUSEHOLD

First name

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* 1. First name

Last name

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* 2. Last name

Primary phone number

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* 3. Primary phone number

Address of flooded residence

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* 4. Address of flooded residence

Date residence flooded

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* 5. Date residence flooded

Date
Residence type

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* 6. Residence type

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

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

Do you have flood insurance

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* 8. Do you have flood insurance

Will you need debris removal assistance from the county?

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

Describe your damage

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* 10. Describe your damage

Describe any agricultural-related damage (if applicable)

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

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