Damage Self Report

Initial Damage Reporting Form

This form is for Initial Damage Reporting only. If there is an emergency, please dial 911.

Please fill out the below form to report storm or disaster-related damage to your home or business.

Submission of this form does not guarantee any type of financial assistance. This form is for information purposes only and will be used when submitting county-wide damage assessments to the State of Florida and FEMA. Information provided on this form may be considered a public record under Chapter 119, Florida Statutes, and may be subject to public disclosure.

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Location

Emergency event:

This report is for:

Damage Report Type is required

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:

Is this a business?

Yes

Don't Know

If yes, enter the business name:

Are you the owner?

Owner

Renter

Do you have homeowner's insurance?

Yes

Don't Know

Do you renter's insurance?

Yes

Don't Know

Do you have flood insurance?

Yes

Don't Know

Personal Impact

Have you been displaced from your residence due to the damage?

Yes

How many people live in your household?

Adults:

Children:

How long will your business be shut down:

How many employees do you have:

Contact Information

Please provide the following information about yourself:

Your First Name:

Your Last Name:

Your Phone Number:

Your Email: