Major Damage Assessment Form

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THE LORAIN COUNTY OFFICE OF EMERGENCY MANAGEMENT AND HOMELAND SECURITY 322 GATEWAY BOULEVARD NORTH, ELYRIA, OHIO 44035

MAJOR DAMAGE ASSESSMENT FORM Name:

_____________________________________________________________________________________________

Address:

_____________________________________________________________________________________________

Phone:

_______________________ (Home) _______________________ (cell) _______________________ (other)

CHECK ONE OR MORE OF THE FOLLOW:

Damage:

____

18 inches of water or more on the first floor living space or water that covers Electrical outlets on the first floor

____

Home with a basement where the water level has compromised the structural integrity of the home (basement walls)

____

Uninhabitable. Will take thirty (30) or more days to repair. Do you have flood insurance?

____ yes ____ no

RETURN THIS PAGE TO THE LORAIN COUNTY OFFICE OF EMERGENECT MANAGEMANT AND HOMELAND SECURITY AS SOON AS POSSIBLE. YOU CAN EMAIL THE FORM TO: TKELLEY@LORAINCOUNTY.US FAX: 440-322-1272. THE FORM CAN BE FILLED OUT ON YOUR COMPUTER BY PUSHING NUMLOCK AND INSERT.

THE LORAIN COUNTY BOARD OF COMMISSIONERS LORI KOKOSKI TED KALO TOM WILLIAMS


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