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Only complete this form if -
- You are a Clark County resident
- You sustained damage to your property as a result of [name incident] between [incident start date] and [incident end date]
- The damage was to your business or your primary residence
Please note: By completing this form you are not applying for disaster assistance. The reason for gathering this damage information is to see if there is enough damage in Clark County for residents to be eligible for federal disaster assistance. Federal assistance is not currently available. If Clark County residents are eligible for this assistance, disaster relief workers will notify you and give you instructions on how to apply.
|Rent or Own?|
|Estimated Pre-Disaster Fair Market Value of STRUCTURE ($):|
Cost estimates: these fields are required. Professional estimates are not required or expected here. Simply provide your own informal estimate of these costs.
|Estimated STRUCTURE Loss in ($)|
|Estimated PERSONAL PROPERTY Loss ($):|
|Primary Cause of Damage:|
|Type of Insurance:|
If the deductible is a percentage of the fair market value, please calculate the amount and enter here.
|Category of Damage:|
Affected: Living unit damaged but still habitable.
|Description of Damages:|