On behalf of the Cook County Department of Homeland Security and Emergency Management (DHSEM), the Village of Kenilworth is collecting preliminary information from residents who experienced flood damage from the April 18, 2013 storm event. Please be aware that this information is only being submitted to Cook County to assist in its application for federal funding. Responses to this survey will not dictate individual assistance or reimbursements.

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* 1. Address Number

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* 2. Street Name/Apartment Number

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* 3. Type of damaged dwelling unit (choose one).

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* 4. Which describes your home situation?

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* 5. What was the depth of water in your basement (indicate feet or inches)? If there was no water in your basement, enter 0. If you do not have a basement, enter N/A.

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* 6. What was the depth of water on your 1st floor (indicate feet or inches). If there was no water on the 1st floor, enter 0. If an apartment is in the basement or upper floor, enter N/A.

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* 7. Is your basement an ESSENTIAL living area? A basement or garden apartment is considered an essential living area, but family rooms and finished basements are NOT essential living areas. If your home is a split level, please indicate so in the comments section.

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* 8. What type of insurance do you currently have? (please check all that apply)

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* 9. Please indicate if any of the following describe the situation in your dwelling.

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* 10. Is there visible structrual damage to the dwelling (such as collapsed basement walls or large foundation cracks)? Structural damage does not include damage to items such as carpet, drywall, or paneling.

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* 11. Please provide your contact information (optional).

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