Damage Self Report

Emergency event:

This report is for:

Damage Report Type is required

Location

Address:

Address is required

Zipcode:

Five digit Zipcode is required

Description

Please describe the damage:

Add Images:

Upload Photos

Please enter the following information if this is your property:

Do you have homeowner's insurance?

Yes

Don't Know

Is this a business?

Yes

Don't Know

If yes, enter the business name:

Contact Information

Please provide the following information about yourself:

Your First Name:

Your Last Name:

Your Phone Number:

Your Email:

Household Demographics

How many people live in your household?

Number of people is required

Names of household members:

Please list the names of all people living in the household.

Required Documentation

You must submit one of the following documents:

Mortgage statement showing your name and property address
Lease agreement with your name and impacted property address
Notarized letter from landlord stating you live at the impacted address at the time of the incident

Upload documentation:

Add Documents

At least one document is required (up to 10 files, 10 MB each)

Certifications

I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that providing false or misleading information may disqualify me from receiving assistance and could be subject to penalties.

I attest that I am normally able to meet my household’s basic needs without assistance. However, due to the nature and impact of the declared disaster, I am currently unable to meet essential needs such as housing, food, and utilities. I am seeking temporary aid to help recover from this emergency situation.

Both certifications are required

NOTE: No funds will be distributed until the status of the property and residency at the property have been confirmed.