VERY IMPORTANT: Once you have completed your survey, BE SURE TO SUBMIT YOUR SURVEY BY CLICKING THE BLUE BOX AT THE BOTTOM OF THE PAGE. Thank you!

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* 1. Do you live in Jefferson County, Texas?

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* 2. Do you have unmet needs as a result of Hurricane Beryl?

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* 3. Name of Contact Person: (You or someone you appoint for us to speak with on your behalf)

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* 4. Please provide a reliable phone number(s) for us to contact you:

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* 5. What is the PHYSICAL address of the damaged property?

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* 6. Please provide a working email address that you routinely check (if you do not have an email, please go to the next question).

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* 7. How many individuals live in your household? (including yourself)

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* 8. Do you have anyone in your household that is disabled? 

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* 9. Do you have anyone in your household that is a US Veteran?

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* 10. Do you have anyone in your household that is 65 or older?

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* 11. Are you a single parent with children living in your home (under the age of 17)?

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* 12. Do you OWN or RENT the damaged property you were living in?

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* 13. Which of the following best describes your damaged home:

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* 14. Did you have homeowners insurance at the time of the disaster?

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* 15. Did you have flood insurance at the time of the disaster?

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* 16. If you are a renter, did you have renters insurance at the time of the disaster?

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* 17. Do you currently have a tarp on your roof?

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* 18. When thinking about damages to your home that have not been repaired, please check all areas of your home that were damaged due to a disaster and need to be evaluated for repairs:

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* 19. Please share any additional information not listed in this application but you feel is important:

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* 20. If your home has storm-related damages, it's very important that you apply for assistance with FEMA and SBA. Do you need assistance completing a FEMA or SBA application?

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* 21. Do we have permission to share your information with other vetted partner organizations that are providing assistance and/or funding for households impacted by disaster so that they may reach out to you?

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