Flood Damage Application

FLOOD DAMAGE APPLICATION

WHEREAS: The undersigned Applicant declares that the property identified below sustained flood-related damage and seeks assessment, documentation, and potential assistance for recovery and restoration; and

WHEREAS: The Applicant acknowledges that submission of this application constitutes a certification of the facts as presented and an authorization for authorized agents to inspect the property, evaluate damage, and to receive relevant records from insurers, contractors, or local authorities for the limited purpose of processing this application;

WHEREAS: The Applicant requests consideration for assistance and understands that approval, funding, or referral to contractors is subject to verification, available resources, and compliance with applicable program requirements.

Applicant Information

Property Information

Date of Flood Event:    Time (if known):

Damage Description and Scope of Work

Provide a concise summary of observed damage. Include affected rooms, materials, and immediate hazards.

Itemized damage and recommended scope of repairs (attach contractor estimates as available):

Insurance and Claims

Immediate Mitigation and Attachments

Have any mitigation measures been undertaken? (check all that apply)

Payment Terms (if applicable)

Application Fee:    Inspection / Administrative Fee:

Payment Schedule / Reimbursement Terms:

Late Payment Penalty (if monies are due from Applicant to program):

Term, Termination, and Notice

Application Effective Date:

This application will remain valid until: unless earlier withdrawn in writing. Notice of withdrawal or additional documentation required shall be provided in writing to the Applicant at the mailing address above within the notice period.

Confidentiality

All non-public information submitted in connection with this application will be treated as confidential to the extent permitted by law. The Applicant expressly consents to disclosure of submitted materials to authorized program reviewers, contractors, insurance carriers, and governmental entities for purposes of verification, inspection, or processing of claims. Confidential information may be disclosed when required by law or legal process.

Authorization and Certification

By signing below, the Applicant certifies under penalty of perjury that the information provided in this application is true, complete, and accurate to the best of Applicant's knowledge. Applicant authorizes authorized agents to enter the property for inspection purposes and to obtain relevant records from insurers, contractors, and municipal authorities for the limited purpose of evaluating this application. Applicant understands that knowingly making a false statement on this application may result in denial of assistance and potential civil or criminal penalties.

Governing Law and Entire Agreement

This application, together with any written attachments or certifications, constitutes the entire understanding between the Applicant and the program regarding the matters set forth herein. Any disputes arising from or related to this application shall be governed by the laws of the state in which the subject property is located, without regard to conflict of laws principles.

Applicant Declaration

I declare under penalty of perjury that the foregoing is true and correct.

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