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Required fields are marked with asterisks (*)

We want to hear from you!

Please complete this form to report damage sustained to your business. There is no guarantee that funding will come available, but we need your reports to try and receive funding.

Full Name:

Email Address:

Phone Number:

Property Address of Business:

Details of damages sustained:

Damage level to my business:

Affected (Some damage to structure or unsafe conditions)

Destroyed (Total loss or damaged to the point it is not economically repairable)

Major Damages (Not habitable or unsafe)

Minor Damages (Damaged but usable with minor repairs)

I have insurance that will help cover my costs:

Yes

Estimated Repair Cost:

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The County Office of Emergency Services (OES)

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