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Please submit the information below to request Flood Assistance in Rockland and Westchester Counties.
Please note that this is an expression of interest, not an application.
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First Name
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Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Street Address Line 1
*
Your answer
Street Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
ZIP Code
*
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Number of people in the household
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Gross Annual Income of the household
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Do you have insurance coverage?
Yes
No
Other:
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Do you have contractor estimates?
Yes
No
Other:
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Brief description of the damage:
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