Report Flood Damage Form

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Please correct the field(s) marked in red below:

Please be advised that this information will be used for statistical purposes and to assist with planning for future events. This information will not be used for emergency assistance or rescue.
1

Address of Damaged Property

2

Owner's Name:

Owner's Name:
3

Owner's Mailing Address:

Owner's Mailing Address:
4

Owner's Primary Phone Number:

5

Owner's Email Address:

6

Resident's Name:

Resident's Name:
7

Resident's Mailing Address:

Resident's Mailing Address:
8

Resident's Primary Phone Number

9

Resident's Email Address:

10
What type of structure was damaged?
What type of structure was damaged?
11
If you selected "Other" please describe:
12
Is anyone currently living in the structure?
Is anyone currently living in the structure?
13
Is this located inside city limits?
Is this located inside city limits?
14
What is the value of the structure (excluding land cost)?
15
What is the age of the damaged structure? (years)
16
Is the structure insured?
Is the structure insured?
17
If yes, specify type of insurance:
If yes, specify type of insurance:
18
What caused the damage?
What caused the damage?
19
If "Other" selected above, please describe:
If structure was flooded, please answer the following:
20
What was the approximate depth of the flood water?
What was the approximate depth of the flood water?
21
What was the structure's foundation type? (Select One)
What was the structure's foundation type? (Select One)
22
How long was water in the structure?
How long was water in the structure?
23
What is the square footage of the structure?
24
Additional Information or Comments:
25
Can we contact you for additional details that may assist these efforts?
Can we contact you for additional details that may assist these efforts?
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.
26
Name of person submitting information:
Please press the submit button when complete.
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