Please complete the following form to place yourself onto the waiting list for
POTENTIAL PARTICIPATION in this program

Please complete the following form to place yourself onto the waiting list for
POTENTIAL PARTICIPATION in this program

FLOOD REPAIR GRANT

Name of Homeowner:

Property Address:

County:

Phone Number:

Number of People in Household:

Gross Monthly Income:

Do you plan to clean up and make repairs?
Yes No
Will you need a contractor to make the needed repairs?
Yes No