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This report is for:
-- SELECT A REPORT TYPE --
Public Facility Damage
Damage Report Type is required
Address is required
Five digit Zipcode is required
Please describe the damage:
Please enter the following information if this is your property:
Do you have homeowner's insurance?
Is this a business?
If yes, enter the business name:
Access and Functional Needs
Do you, or anyone in your household, identify as a person with a disability?
If so, what is the nature of your disability?
If Other, please list
Has any of your equipment been lost or damaged as a result of this disaster?
If so, please list the lost or damaged item(s)
Please provide the following information about yourself:
Your First Name:
Your Last Name:
Your Phone Number:
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