Butler County Ohio, Emergency Management Agency

Damage Report Form
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After a disaster event, please fill out and submit this form This Damage Report Form is provided as a service to the citizens of Butler County, Ohio. This form does NOT replace forms necessary to receive disaster assistance from FEMA, or other relief agencies. This form does help local agencies to assess the need for assistance. Applicants who plan to register for aid should be prepared to provide basic information about themselves (name, permanent address, phone number, insurance coverage and other information to help substantiate losses). Note: Fields labeled in bold are required
First Name:		Last Name:
Home Address:
City:		State: Zip:

Day Phone:		Evening Phone:
Email:

Type of Structure:	Home Business	Status:	Own Rent

Dwelling Type:	Single Family Multi-Family Mobile Home	Insurance:	Yes No

Extent of Damage:	Destroyed Major Minor Still Livable	Flooding Damage:	Basement Only 1-2 Feet 1st. Floor 2-5 Feet 1st. Floor Over 5 Feet 1st. Floor

Briefly describe the damage:

315 High Street, Suite 670
Hamilton, Ohio 45011
Phone: (513)785-5810(24 Hour Access)