THE LORAIN COUNTY OFFICE OF EMERGENCY MANAGEMENT AND

HOMELAND SECURITY 322 GATEWAY BOULEVARD NORTH, ELYRIA, OHIO 44035

MAJOR DAMAGE ASSESSMENT FORM

Name: _____________________________________________________________________________________________ Address: _____________________________________________________________________________________________ Phone: _______________________ (Home) _______________________ (cell) _______________________ (other)

CHECK ONE OR MORE OF THE FOLLOW:

Damage: ____ 18 inches of water or more on the first floor living space or water that covers

Electrical outlets on the first floor

____ Home with a basement where the water level has compromised the structural integrity of the home (basement walls)

____ Uninhabitable. Will take thirty (30) or more days to repair.

Do you have flood insurance? ____ yes ____ no RETURN THIS PAGE TO THE LORAIN COUNTY OFFICE OF EMERGENECT MANAGEMANT AND HOMELAND SECURITY AS SOON AS POSSIBLE. YOU CAN EMAIL THE FORM TO: TKELLEY@LORAINCOUNTY.US FAX: 440-322-1272. THE FORM CAN BE FILLED OUT ON YOUR COMPUTER BY PUSHING NUMLOCK AND INSERT.

THE LORAIN COUNTY BOARD OF COMMISSIONERS LORI KOKOSKI TED KALO TOM WILLIAMS