Damage Assessment Form

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
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
Insurance Information
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

: Hour Minutes AM/PM Option
Should be Empty:

Damage Assessment Form

Damage Level Report

Do you have any immediate needs?