PLEASE ONLY ONE RESPONSE PER BUSINESS

* 1. Business name

* 2. First name

* 3. Last name

* 4. Best phone number

* 5. Address of flooded facility

* 6. Date facility flooded

Date
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* 7. Have you ceased operations

* 8. Have you experienced economic injury

* 9. Business loss/impacts (please select best option)

* 10. Estimated cost of repair (you may not know, but please provide best guess)

* 11. Do you have flood insurance

* 12. Estimated number of unemployed as a result of this damage

* 13. Will you need debris removal assistance from the county

* 14. Describe your damage

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