Homeowner's Information Form

DRN Homeowner Information Form

The information you share will help DRN thoughtfully connect you with a dedicated homeowner advocate and a trusted DRN builder to walk with you through your rebuilding journey.
Timestamp

MonthDayYear
Date
Hour Minutes
Contact Information
Applicant Name*

First NameLast NameSuffix
Preferred Name (if different)

First NameLast Name
Cell Number*
Please enter a valid cell number.Format: (000) 000-0000.
Email Validation Status*
Email Address*
example@example.com
Confirm Email Address*
example@example.com
The email addresses do not match. Please correct before submitting.
CallTextEmail
EnglishSpanishOther

When are you available to be contacted? (Check all that apply)

Household Information
Current Address (Where you're staying now)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In my undamaged homeIn my damaged homeStaying with family/friendsIn a temporary rentalIn a hotelIn a shelterOther
Number of adults in your personal household?
Number of children in your personal household?
SeniorsDisabilities or access needsMedical considerationsNonePrefer not to say
Property Information
Damaged Property Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OwnRent
Primary DwellingDetached GarageSwimming PoolShedAdditional Dwelling Unit (ADU)Other

How were the listed structures on the property affected by the fire? Leave choices blank if the listed structure did not exist on the property.

Rows	Dwelling	Detached Garage	ADU	Shed
Destroyed
Major Damage (uninhabitable)
Minor Damage (habitable with repairs)
Smoke/Soot/Ash Damage (habitable)
No Damage

DRN Homeowner Information Form