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Please fill this out to the best of your ability. If you are unable to determine a cost estimate, please leave blank.
Key criteria: SAFE and SANTARY Guidelines: Are conditions livable? Has disaster interrupted utility services such as water, sewer, power, heat/AC? Is the structure stable? Are there other circumstances that make it unsafe or unsanitary to continue living there?
Number of Occupants Displaced / Number of Days expect to be Displaced
If staying with friends / relatives, in a hotel / motel, or a public shelter, please provide name and address.
Check all that apply: I have........
May include estimate if available
Please include a "best guess" estimate of each damaged component if possible.
Include Type / Number of Livestock and Cost Estimate.
Include Crop Type / Acres affected and Cost Estimate.
Include Building / Structure Type and Cost Estimate.
Any pictures or additional information, please attach files.
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