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Contact information:

Contact Person (#1):

Contact Person (#2 - optional):

About the property:

Is the affected property Commercial or Residential? CommercialResidential

Address of property:


Insurance Information:

Do you have homeowners insurance? YesNo
If Yes:

Do you have flood insurance? YesNo
If Yes:

Mortgage Information:

Do you have a mortgage? YesNo
If Yes:

Is there an existing 2nd mortgage on your home? YesNo

Funding Information

What is your credit score? GoodFairPoor
Are you funded by any of the following? (select all that apply)FEMA FundingSAH FundingCBDG FundingGrant FundingCharitable FundingConventional LoanAvailable Cash

About the Damage

Are you above Base Flood Elevation (BFE)? YesNo
Do you have more or less than 50% damage? More than 50%Less than 50%

Upload pictures of the affected property (if you have more than 10 images, please let us know):

Special Considerations

Do you have anyone with special needs, such as elderly or disabled, living with you? YesNo