NOTE: This is an updated version of the form you may have already completed. Because of the new opportunity for reimbursement, please update any information you have provided before. To enable us to continue to process your application, please provide the information requested below. How many bedrooms were in your damaged residence at the time of the storm? __________ Have you received a substantial damage letter from the Flood Plain Manager? Yes No Was your home destroyed or so seriously damaged that you believe it is likely a new home will have to be built rather than repairing your home? Yes No Does anyone in your household have a disability or mobility impairment that requires special adaptations to your home (such as a wheel chair ramp or lowered cabinets) Yes No If yes, please enter the name of the individual_______________________. Please describe the accommodations needed.________________________________________________________ Do you currently have a builder working on your home? Yes No If yes, please provide contact information for your builder. If you used more than one contractor or sub-contractor, please attach contact information for each. Please provide the contract you have with the builder Builder Company Name Representative: Address Telephone: Email Address: EIN #: (if known) Date contact was signed: State ID #: (if known)
NOTE: This is an updated version of the form you may have already completed. Because of the new opportunity for reimbursement, please update any information you have provided before. To enable us to continue to process your application, please provide the information requested below. How many bedrooms were in your damaged residence at the time of the storm? __________ Have you received a substantial damage letter from the Flood Plain Manager? Yes No Was your home destroyed or so seriously damaged that you believe it is likely a new home will have to be built rather than repairing your home? Yes No Does anyone in your household have a disability or mobility impairment that requires special adaptations to your home (such as a wheel chair ramp or lowered cabinets) Yes No If yes, please enter the name of the individual_______________________. Please describe the accommodations needed.________________________________________________________ Do you currently have a builder working on your home? Yes No If yes, please provide contact information for your builder. If you used more than one contractor or sub-contractor, please attach contact information for each. Please provide the contract you have with the builder Builder Company Name Representative: Address Telephone: Email Address: EIN #: (if known) State ID #: (if known) Date contact was signed: