Full Name *
Primary Phone Number *
Secondary Phone Number
Work Phone Number
Email Address *
Damaged Property Address *
Is the Damaged Property in an Unincorporated Area
of the County?
Full Mailing Address *
Date of Birth *
Do you own or rent this property?
Are you currently the owner of this property? *
Was this property your primary residence at the time
of Hurricane Harvey?
Was your home impacted by Hurricane Harvey?
Did you have water in your home?
If yes, how high was the water in your home?
0 – 15″
15 – 24″
24 – 4 8″
If yes, what caused the flooding?
Did your home have wind damage?
If yes, describe the wind damage:
Are you currently displaced?
Does your family have any social service needs, such
as food bank, assistance for the elderly or disabled?
If yes, describe these needs:
Do you have homeowner’s or renter’s insurance?
Do you have flood insurance?
Do you have windstorm insurance?
Have you applied for disaster assistance related to
If Other, list the agencies with which you have applied
for disaster assistance:
How many people live in your household?
What is your estimated annual household income
(total of everyone, ages 18 and older)?
Is anyone in the household 62 years old or older?
Is anyone in the household under the age of 5 years?
Is anyone in your household diasabled or receiving
By submitting this survey, I authorize the release
of this information to the appropriate Federal,
state, and local agencies including but not
limited to Galveston County and its designees.
You can go online to http://www.galvestoncountytx.
disasterassistance.gov to complete the form. If
you do not have a computer, you can complete
the form at your local library