Individual FEMA Information Form
Complete this form to provide your information for the FEMA report. This is critical to receiving funding! Estimates are okay! Formal applications for assistance will come at a later time. All information is reported to the Division of Emergency Management.
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First Name *
Last Name *
Street Address *
Street Number *
Street Name *
City *
Owner or Renter? *
County Assessed Structure Value (optional)
ESTIMATED Structure Loss in Dollars (based on what you know today, use high end of range expected) This info is being used to mobilize resources and is not an application for funds. *
ESTIMATED Personal Property Loss in Dollars *
Primary Cause of Damage
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Type of Insurance
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Deductible Amount
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Category of Damage
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Description of Damages
Contact Name
Contact Phone
Contact Email
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