Laserfiche WebLink
<br />-- -'""'-' ....-r.'-t~ <br /> <br />~ULU. DODES EOC <br /> <br />869 P10 <br /> <br />'.. . 'It <br /> <br />" <br /> <br />.~"'"'''' . <br />1;11-.' 0 <br />. <br />. . <br />. <br />. . <br />. . <br />. . <br />.. .It' <br /> <br />Town of Firestone <br /> <br />150 Buchanan · P.O. Box 100 . Firestone, CO . 80520.0100 . (303) 833.3291 <br /> <br />I, NAME I <br /> .__~a <br /> la. OWnir: YES NO lb. Renterl YES NO <br />2. ADDRESS (street ~ bOK number) I <br />3. TOWN: 4. Z IPI <br /> <br />5. TELEPHONE (homell <br /> <br />6. WHERE DID THE WATER COME FROM (How did it get into your homel? <br />NOTE I Check ,II that 'pply. <br /> <br />Finished Basement <br /> <br />Unllnished Basement <br /> <br />Wall . <br /> <br />Windows <br /> <br />Sewer drain <br /> <br />Other (HII Inl <br /> <br />7. DO YOU HAVE FLOOD INSURANCE? YES <br /> <br />NO <br /> <br />If !!..9... go to question 8 <br /> <br />7a. Insurance Company: <br /> <br />Pelley' <br /> <br />a. PLEASE DESCRIBE THE TYPE OF DAMAGE AND VALUE I <br /> <br />DESCRIPTION <br /> <br />VALUE <br /> <br />a. <br /> <br />b. <br /> <br />c. <br /> <br />d. <br /> <br />9. IF FINANCIAL ASSISTANCE IN THE FORM OF LOW INTEREST LOANS IS AVAILABLE, <br />WOULD YOU BE INTERESTED ? YES NO <br /> <br />10. IF ~, HOW MUCH WOULD YOU NEED? $ <br />II. HAVE yOU ~EEN CONTACTED BY THE RED CROSS? YES NO <br /> <br />12. WOULD YOU BE INTERESTED IN RECEIVING ADDITIONAL INFORHATION ON HOW yOU <br />CAN PREVENT DAlIAGE IN THE FUTURE? YES _ NO _ <br /> <br />I HEREBY AUTHORIZE THE RELEASE OF INFORMATION TO THE TOWN OF FlRe :ONE, WELD <br />COUNTY OFFICE OF EMERGENCY MANAGEMENT, COLORADO DIVISION OF EMERGENCY <br />SERVICES, DISASTER PREPAREDNESS AND PLANNING AGENCIES OR THE RED CROSS, AS <br />WELL AS INFORMATION GIVEN TO THE RED CROSS; FOR THE PURPOSE OF DISASTER <br />PLANNING AND DAMAGE ASSESSMENT ~ . <br /> <br />SIGNED: <br /> <br />DATE: <br /> <br />File, <br /> <br />