Damage Assessment Form
Please use this form to report your damages to Franklin County EMA. Completion of this form in no way guarantees local, state, or federal assistance. Information submitted within this form will be used by Franklin County and its response partners to determine what assistance is needed and severity of damages.Your name and contact information will not be released to anyone outside of the response.If you need emergency assistance please call 911
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Type
Single Family Home
Multi-Family
Mobile Home
Business
Farmland
Other
Damage Level Report
Severity of Damage
Inaccessible: Your home or business may have damage but you cannot get to it.
Completely Destroyed: You home is so damaged that will not be able to be repaired.
Partially Destroyed: Your home should be able to be repaired but has major damage.
Minor Damage: Your home has damage, but you can stay in it safely.
Unaffected: Your home is fine, but property has sustained damage.
Property Insurance Status
Insured
Uninsured
Unknown
Insurance Information
Homeowners
Renters
Business or Agricultural
Flood
Sewer
None/Uninsured
Do you have any immediate needs?
If you need Shelter, Food, or other NON-EMERGENCY assistance please list them here. If you need EMERGENCY assistance please dial 911.
Property Damage Photo
Browse Files
Cancel
of
Property Damage Photo #2
Browse Files
Cancel
of
Property Damage Photo #3
Browse Files
Cancel
of
Additional Comments?
Date
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: