County of Santa Barbara

Local Assistance Center Intake Form

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* 1. Your Evacuation Date

Please enter the date you were evacuated

Date

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* 2. Your Contact Information

First Name *

Last Name

Address *

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 3. How many people are in your household?

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* 4. How many pets are in your household?

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* 5. Was your home damaged?

Yes

No

Don't Know

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* 6. Are you self-employed or a business owner?

Yes

No

I don't Know