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Flood Damage Assessment Survey

  1. This survey is not an application for individuals to receive funds. Everyone with flood damage should complete this survey, including those who have already called to report flooding. The Village will let registrants know if and when funding becomes available. Information submitted will be used as an aid for providing information to the state and federal government. Additionally, it will also be used to register residents to receive updates regarding disaster assistance information via e-mail and to create a database of flooding causes.

  2. Contact Information - (Owner / Occupant)

    Fields marked with an asterisk are required and must be completed.

  3. e.g. 000-000-0000

  4. Please enter a valid e-mail address for future contact. e.g. johndoe@email.com

  5. Property Information

    Please enter the property information below.

  6. Please enter ONLY the address number (e.g. 888, 2221, etc.)

  7. Enter ONLY your street name (e.g. Main St., Wilson Ave., etc.)

  8. If a business is present at address, please record the name here.

  9. Survey Information

    Please answer the following questions to the best of your knowledge.

  10. Flooding - Basement*

  11. Enter the water depth. If seepage, enter 0.

  12. Flooding - 1st Floor*

  13. Enter the water depth. If seepage, enter 0.

  14. Basement Bedroom*

  15. Insurance*

  16. If you answered "YES" to above, please describe your damage here.

  17. Additional Structural Damage Selections

  18. Leave This Blank:

  19. This field is not part of the form submission.