Subgrant Project Application
FEMA HMA
Subgrant Project Application
|Applicant Information |
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|* Name of Applicant |
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|* State |
|MD |
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|Congressional District |
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|* Type of Applicant |
|[pic]State Government |
|[pic]Local Government |
|[pic]Indian Tribal Government |
|[pic]Special Governmental District |
|[pic]Private Non-Profit |
|[pic]Other |
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|If Private Non-Profit, |
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|Describe the legal status, function, and facilities owned: |
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|State Tax Number: (e.g. 11-111111) |
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|Federal Tax Number: (e.g. 11-111111) |
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|If Other, please specify: |
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|* Federal Employer Identification Number (EIN). If Indian Tribe, this is Tribal Identification Number. |
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|What is your DUNS Number? |
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|* Are you the application preparer? |
|[pic]Yes [pic]No |
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|* Is the application preparer the Point of Contact? |
|[pic]Yes [pic]No |
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|* Is the applicant delinquent on any Federal debt? |
|[pic]Yes [pic]No |
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| If yes, type explanation: |
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|* Community: |
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|Is this a small, impoverished community? |
|(Note: For PDM-C grants, a response to this question is required.) |
|[pic]Yes [pic]No |
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|Contact Information |
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|Point of Contact Information |
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|Title |
|[pic]Mr. |
|[pic]Ms. |
|[pic]Mrs. |
|[pic]Dr. |
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|* First Name |
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|Middle Initial |
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|* Last Name |
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|Title |
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|* Agency/Organization |
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|* Address 1 |
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|Address 2 |
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|* City |
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|* State |
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|* ZIP |
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|* Phone |
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|Fax |
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|* Email |
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|Alternate Point of Contact Information |
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|Title |
|[pic]Mr. |
|[pic]Ms. |
|[pic]Mrs. |
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|First Name |
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|Middle Initial |
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|Last Name |
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|Title |
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|Agency/Organization |
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|Address 1 |
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|Address 2 |
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|City |
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|State |
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|ZIP |
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|Phone |
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|Fax |
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|Email |
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|Community Profile |
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|Mitigation Plan Information |
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|* Is the entity that will benefit from the proposed activity covered by a current |
|FEMA-approved multihazard mitigation plan in compliance with 44 CFR Part 201? |
|[pic]Yes [pic]No [pic]Not Known |
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|If yes, please answer the following: |
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|* What is the name of the plan? |
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|* What is the type of plan? |
|[pic]Local MultiJurisdictional Multihazard Mitigation Plan |
|[pic]Local Multihazard Mitigation Plan |
|[pic]Tribal (Local) MultiJurisdictional Multihazard Mitigation Plan |
|[pic]Tribal (Local) Multihazard Mitigation Plan |
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|* When was the current multihazard mitigation plan approved by FEMA? |
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|* Describe how the proposed activity relates to or is consistent with the FEMA-approved mitigation plan. |
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|If no or not known, please answer the following: |
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|* Does the entity have any other mitigation plans adopted? |
|[pic]Yes [pic]No [pic]Not Known |
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|If yes, please provide the following information. |
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|Plan Name |
|Plan Type |
|Date Adopted |
|Attachment |
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|* Does the State/Tribe in which the entity is located have a current FEMA-approved mitigation plan in compliance with 44 CFR Part 201? |
| [pic]Yes [pic]No |
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|If yes, please answer the following: |
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|* What is the name of the plan? |
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|* What is the type of plan? |
|[pic]Enhanced State Multi-hazard Mitigation Plan |
|[pic]Enhanced Tribal Multi-hazard Mitigation Plan |
|[pic]Standard State Multi-hazard Mitigation Plan |
|[pic]Standard Tribal Multi-hazard Mitigation Plan |
|[pic]State Mitigation Plan - Pre DMA2000 |
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|* When was the current mitigation plan approved by FEMA? |
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|* Describe how the proposed activity relates to or is consistent with the State/Tribe's FEMA-approved mitigation plan. |
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|Mitigation Activity Information |
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|* What type of activity are you proposing? (Please choose activities from Appendix A below). |
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|If you selected Other or Miscellaneous, above, please specify: |
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|* Title of your proposed activity(should include the type of activity and location): |
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|* Are you doing construction in this project? |
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|[pic]Yes [pic]No |
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|Hazard Information |
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|Problem Description: please describe the problem to be mitigated. Include the geographic area in your description. |
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|Enter the Latitude and Longitude coordinates for the project area. |
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|Latitude: |
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|Longitude: |
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|Hazards |
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|Select hazards to be mitigated: |
|[pic]Biological |
|[pic]Chemical |
|[pic]Civil Unrest |
|[pic]Coastal Storm |
|[pic]Crop Losses |
|[pic]Dam/Levee Break |
|[pic]Drought |
|[pic]Earthquake |
|[pic]Fire |
|[pic]Fishing Losses |
|[pic]Flood |
|[pic]Freezing |
|[pic]Human Cause |
|[pic]Hurricane |
|[pic]Land Subsidence |
|[pic]Mud/Landslide |
|[pic]Nuclear |
|[pic]Other |
|[pic]Severe Ice Storm |
|[pic]Severe Storm(s) |
|[pic]Snow |
|[pic]Special Events |
|[pic]Terrorist |
|[pic]Tornado |
|[pic]Toxic Substances |
|[pic]Tropical Cyclones |
|[pic]Tsunami |
|[pic]Typhoon |
|[pic]Volcano |
|[pic]Windstorms |
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|If other hazards, please specify |
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|FIRM Information |
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|* Is the project located within hazard area? |
|[pic]Floodway |
|[pic]Floodplain |
|[pic]Other identified high hazard area |
|[pic]No |
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|If other identified high hazard area, please specify: |
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|*Is there a Flood Insurance Rate Map (FIRM) or Flood Hazard Boundary Map (FHBM) available for your project area? |
|If you have selected Yes, the following three fields are required: |
|[pic]Yes [pic]No |
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|Enter FIRM Panel Number: |
| [pic]check if Not Applicable |
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|Mark your project site on the FIRM/FHBM (even if it is out of the floodplain) |
|[pic]Electronic map attached |
|[pic]Hard copy provided |
|[pic]Not Applicable |
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|Select Flood Zone Designation |
|[pic]C, X [pic]V0 |
|[pic]B, X [pic]AH |
|[pic]N [pic]V1-30, VE |
|[pic]AR [pic]V |
|[pic]A99 [pic]E |
|[pic]A1-30, AE [pic]M |
|[pic]A [pic]D |
|[pic]A0 [pic]P |
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|Scope of Work |
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|* What are the goals and objectives of this activity? |
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|* Briefly describe the need for this activity. |
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|* Describe the problems this activity will address. |
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|*Describe the methodology for implementing this activity. |
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|Enter Work Schedule |
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|Description Of Task |
|Starting Point |
|Unit Of Time |
|Duration |
|Unit Of Time |
|Work Complete By |
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|* Estimate the total duration of the proposed activity: |
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|[pic]Day(s) |
|[pic]Week(s) |
|[pic]Month(s) |
|[pic]Year(s) |
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|Properties |
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|Property Owner's Name |
|Damaged Property Address |
|City |
|State |
|Repetitive |
|Loss |
|Zip Code |
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| Damaged Property Address: |
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|* Address line 1 |
|Street Name: |
|Street Type: |
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|Address line 2 |
|Unit Type: |
|Number: |
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|* City |
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|* County |
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|* State |
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|* ZIP |
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|Owner Information: |
|If the owner is an organization, then split this information in the First and Last Name. |
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|* First Name |
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|Middle Name |
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|* Last Name |
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|Phone |
|Home |
|Office |
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|Cell |
|Other |
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|[pic]Owner's Mailing Address (check if this address is the same as Property Address above): |
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|Address line 1 |
|Street Number: |
|Direction: |
|Street Name: |
|Street Type: |
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|Address line 2 |
|Unit Type: |
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|Other (PO Box, Route, etc) |
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|City |
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|State |
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|ZIP |
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|*Does this property |
|have other co-owners |
|or holders of recorded interest? |
|[pic]Yes [pic]No |
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|If Yes, Enter Co-owner or Owner of Property Interest Information: |
|If the co-owner is an organization, then split this information in the First and Last Name. |
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|*First Name |
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|Middle Name |
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|*Last Name |
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|Phone |
|Home |
|Office |
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|Cell |
|Other |
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|Co-owner's Mailing Address: |
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|[pic]Owner's Mailing Address [pic]Property Address [pic]None |
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|Address line 1 |
|Street Number:: |
|Street Name: |
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|Address line 2 |
|Unit Type: Number: |
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|Other (PO Box, Route, etc) |
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|City |
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|State |
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|ZIP |
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|Property Information: |
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|Age of structure (year built) |
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|SHPO Review |
|[pic]Yes |
|[pic]No |
|[pic]Not Applicable |
|[pic]Unknown |
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|SHPO |
|Review Date |
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|Structure Type |
|[pic]2-4 Family |
|[pic]Manufactured Home |
|[pic]Multi-Family Dwelling - 5 or More Units |
|[pic]Non-residential - Private |
|[pic]Non-residential - Public |
|[pic]Other (Specify in Comments) |
|[pic]Single Family |
|[pic]Vacant Land |
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|Other |
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|Foundation type |
|[pic]Basement |
|[pic]Crawl Space |
|[pic]Elevated on Piers, Piles, Posts or Columns |
|[pic]Other (Specify in Comments) |
|[pic]Slab on Grade |
|[pic]Vacant Land |
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|Other |
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|Basement |
|[pic]Yes [pic]No |
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|Type of Residence |
|[pic]Not Applicable |
|[pic]Other |
|[pic]Owner Occupied- Secondary Residence |
|[pic]Owner Occupied-Principal Residence |
|[pic]Rental |
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|Other |
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|Parcel Number |
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|Property Tax Identification Number |
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|Latitude |
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|Longitude |
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|Does this property have a NFIP Policy Number? |
|(Note: For SRL grants, a response to this question is required.) |
|[pic]Yes [pic]No |
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|Number |
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|Insurance Company |
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|* Select hazards to be mitigated: |
|[pic]Biological |
|[pic]Chemical |
|[pic]Civil Unrest |
|[pic]Coastal Storm |
|[pic]Crop Losses |
|[pic]Dam/Levee Break |
|[pic]Drought |
|[pic]Earthquake |
|[pic]Fire |
|[pic]Fishing Losses |
|[pic]Flood |
|[pic]Freezing |
|[pic]Human Cause |
|[pic]Hurricane |
|[pic]Land Subsidence |
|[pic]Mud/Landslide |
|[pic]Nuclear |
|[pic]Other |
|[pic]Severe Ice Storm |
|[pic]Severe Storm(s) |
|[pic]Snow |
|[pic]Special Events |
|[pic]Terrorist |
|[pic]Tornado |
|[pic]Toxic Substances |
|[pic]Tropical Cyclones |
|[pic]Tsunami |
|[pic]Typhoon |
|[pic]Volcano |
|[pic]Windstorms |
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|Other |
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|* Damage Category |
|[pic]0-49% Damaged |
|[pic]100% Damaged |
|[pic]50-99% Damaged |
|[pic]Not Applicable |
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|Pre Event Fair Market Value |
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|Benefit Cost Analysis Performed |
|[pic]Yes [pic]Not Applicable |
|[pic]No [pic]Unknown |
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|Benefit Cost Ratio |
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|Repetitive Loss Structure |
|[pic]Yes |
|[pic]No |
|[pic]Unknown |
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|Property Locator Number |
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|Number of Losses |
|[pic]2-3 Losses Cumulatively > building Fair Market Value |
|[pic]2-3 Losses Cumulatively ................
................
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