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Department of Emergency Management



 

Private Damage Reporting Form


Please fill out the Private Damage Reporting Form completely. This will help document damage in our community and assist in requesting funds from the State and Federal Emergency Management Agencies.

If this incident is declared a Presidential Disaster you may be asked to fill out other forms for the Federal Emergency Management Agency or Small Business Administration.

Please submit this completed form by clicking the "submit" button at the bottom of this page.

 

Name:
 
Street Address:
 
City:
 
State:
 
Zip
 
Phone:
 
EMail:
 
Confirm EMail:
 

Occupant:
 
Habitable:
 

    

Accessible
      

Insurance Type:
 
Deductible Amount:
 

Parcel Number:
 
Percentage of Structure Fair Market Value:
 
Estimated Fair Market Value:
 
Estimated Structure Loss:
 
Estimated Personal Property Loss:
 
Damage Categories
          
  Destroyed: Total loss.
  Major: Significant structural damage greater than 50 % value.
  Minor: Conditional use, repairable in less than 30 days, few thousand dollars worth.
  Affected: Living unit damaged, but still inhabitable.


  Date And Description of Damage:  
   
 

Have you incurred damage from this type of incident before and when?
 
   

I hereby state that the above information is true and correct.