INDIVIDUAL ASSISTANCE
INITIAL DAMAGE ASSESSMENT For Flood Events
County/City
Date of Event
1
2
3
4
5
6
ADDRESS NUMBER
STREET NAME/ APARTMENT NUMBER
SF/MF/M H/B
OWN/ RENT
DEPTH - BASEMENT
DEPTH - 1st FLOOR
Completed By:
Page
Phone Number:
of
7 BASEMENT LIVING AREA - Y or N
Date(s) of Assessment:
SSESSMENT
Form Revised 11/2010
ts Type of Event 8 INS. - H/R/F
e(s) of Assessment:
9
10
STRUCTURAL DAMAGE - Y or N
COMMENTS
Start: End: