Disaster Repair: Rebuild Request Please fill out the form below and we will be in touch with you as soon as possible. By providing as much information as possible, you will expedite the process. Fields with an * are required. Contact information: Contact Person (#1): Full Name:* Phone:* Email*: About the property: Is the affected property Commercial or Residential? CommercialResidential Address of property: Street Address (line 1):* Street Address (line 2): City:* State:* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code:* Insurance Information: Do you have homeowners insurance? YesNo Do you have flood insurance? YesNo Mortgage Information: Do you have a mortgage? YesNo Is there an existing 2nd mortgage on your home? YesNo Funding Information Are you funded by any of the following? (select all that apply)FEMA FundingSAH FundingCBDG FundingGrant FundingCharitable FundingConventional LoanAvailable Cash About the Damage What type of damage did your property incur: FireSmokeWindWater Approximate square footage of the property damaged: Are you above Base Flood Elevation (BFE)? YesNo Do you have more or less than 50% damage? More than 50%Less than 50% If flooded, how high was the water line? Briefly describe the type of damage to your property: Special Considerations Do you have anyone with special needs, such as elderly or disabled, living with you? YesNo How did you hear about us? Additional Comments: Please leave this field empty.