PLEASE ONLY ONE RESPONSE PER BUSINESS

Business name

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* 1. Business name

First name

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* 2. First name

Last name

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* 3. Last name

Best phone number

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* 4. Best phone number

Address of flooded facility

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* 5. Address of flooded facility

Date facility flooded

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* 6. Date facility flooded

Date
Have you ceased operations

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* 7. Have you ceased operations

Have you experienced economic injury

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* 8. Have you experienced economic injury

Business loss/impacts (please select best option)

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

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

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

Do you have flood insurance

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* 11. Do you have flood insurance

Estimated number of unemployed as a result of this damage

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

Will you need debris removal assistance from the county

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

Describe your damage

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* 14. Describe your damage

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