Director: Earl Eues (985) 873-6357

This damage assessment form is only preliminary. If you receive damage to your home or business, please complete the form. In the event a Federal Declaration is granted and FEMA is activated, the Office of Homeland Security and Emergency Preparedness will be in touch with you to make sure you have the proper contact numbers for FEMA.

	**Name:
	**Address:
	E-mail:
	Tel:

	Insurance:	Yes	No
	Home:	Rent	Own

Number of people in residence:

 Brief Description of Damage:

** Enter the code from the image below.