Hurricane Ike Damage Registration

	Address of Damaged Property:

	Owner's name: Owner's mailing address: Owner's home phone: Mobile phone:  Owner's email address:

	Name of resident (if different):  Resident’s mailing address:  Resident's home phone:  Mobile phone:  Resident’s email address:

	What type of structure was damaged: House Travel trailer Barn/Shop Manufactured home Business Other If other structure selected above please describe:

	Is anyone currently living in the structure: Yes No	Is this located inside city limits: Yes No

	What is the value of the structure (excluding land cost):

	What is the age of the damaged structure (in years):

	Is the structure insured: Yes No
		If yes, specify type of insurance: Homeowners Renters Flood

	What caused damage:
	Wind Flood Other

	If other damage selected above please describe:

	If structure was flooded, please answer the following: Feet Inches What was the approximate depth of the flood water: How long was water in the structure: Number of days Number of hours

Additional information or comments:

	Can we contact you for additional details that may assist these efforts:  Yes No

	Please be advised that this information will be used for statistical purposes and to assist with planning for future events.  The information provided may be shared with other government agencies, such as local municipalities and FEMA.  This information will not be used for emergency assistance or rescue.

	Name of individual submitting information:

	Date of submittal:

	Please press this button to submit your information  -->
		Will you require debris to be picked up? Yes No