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Home / News / GALVESTON COUNTY DISASTER OUTREACH FORM

GALVESTON COUNTY DISASTER OUTREACH FORM

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Contact Information
Full Name *
Primary Phone Number *
Secondary Phone Number
Work Phone Number
Email Address *
Damaged Property Address *
City *
State *
Zip *
Subdivision
Is the Damaged Property in an Unincorporated Area
of the County?
Yes
No
Full Mailing Address *
Additional Information
Date of Birth *
Do you own or rent this property?
Own
Rent
Are you currently the owner of this property? *
Yes
No
Was this property your primary residence at the time
of Hurricane Harvey?
Yes
No
Was your home impacted by Hurricane Harvey?
Yes
No
Did you have water in your home?
Yes
No
If yes, how high was the water in your home?
0 – 15″
15 – 24″
24 – 4 8″
48″+
If yes, what caused the flooding?
Storm Surge
Rain
Uncertain
Did your home have wind damage?
Yes
No
If yes, describe the wind damage:
Are you currently displaced?
Yes
No
Does your family have any social service needs, such
as food bank, assistance for the elderly or disabled?
Yes
No
If yes, describe these needs:
Do you have homeowner’s or renter’s insurance?
Yes
No
Do you have flood insurance?
Yes
No
Do you have windstorm insurance?
Yes
No
Have you applied for disaster assistance related to
Hurricane Harvey?
FEMA
Red Cross
Other
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?
Yes
No
Is anyone in the household under the age of 5 years?
Yes
No
Is anyone in your household diasabled or receiving
disability benefits?
Yes
No
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.
gov/hd/Pages/DisasterOutreach.aspx or
disasterassistance.gov to complete the form. If
you do not have a computer, you can complete
the form at your local library

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