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2. 
   
   
4. Please fill out this form if you have water damage or flooding from the storm on June 25 - 26, 2021.
   The purpose of this form is to collect information only for reporting to the State pursuant to Public Act 390 of 1976 and is not mechanism for any other type of reimbursement or financial assistance.

   This is not a damage claim form pursuant to Public Act 222 of 2001.

   All information provided in this form is subject to Freedom of Information Act requests subject to State law.
6. Personal Information
8. Name:*
9. Address:*
11. Phone Number:*
12. Email:
14. Number of People in House (Adults/Children):
16. Damage Information
18. Do you have water damage?*

    1. Yes
    2. No
20. What type of structure received damage?
    (Check all that apply)*

    1. Single Family Home
    2. Vacation Home / Cottage
    3. Manufactured Home
    4. Apartment / Rental Unit
    5. Business
    6. Public Facility
    7. Non-Profit Organization
22. What level of floor was affected?
    (Check all that apply)*

    1. Crawl Space
    2. Basement
    3. First Floor
    4. Second Floor
    5. Any Other Floor
24. If there was damage to livable space within the building, what percentage of the space is unlivable?*

    1. 20%
    2. 40%
    3. 60%
    4. 80%
    5. 100%
26. If the basement had water damage, does the basement include livable space?
    (Examples: bedroom, finished basement, etc.)*

    1. Yes
    2. No
28. What is the overall level of damage within the building?*

    1. Affected - minimal damage, mostly cosmetic with less than 3 inches of water
    2. Minor Damage - under 50% of area damaged with 3 to 18 inches of water
    3. Major Damage - over 50% of area damaged with over 18 inches of water
    4. Destroyed - 100% of repair costs exceed the value of the structure
30. Please provide a brief description of your loss.*
32. Insurance Information
34. Do you have insurance coverage for the structure?*

    1. Yes
    2. No
36. Does your insurance cover the loss?*

    1. Yes
    2. No
38. Insurance Coverage (If yes, please provide the name of your carrier):
40. What amount of the loss is covered by your insurance, if applicable?*

    1. In Full
    2. Partially
    3. Not at All
42. What is the total estimated value of your loss?*
44. Explanation/ Additional Comments:
46. Photo Uploads
48. The deadline for Flood Damage paperwork is Thursday, July 1, 2021.
    You can now fill out the paperwork online at www.cityofinkster.com and also come into City Hall or DPS office at 26900 Princeton.
    You must submit copies of your pictures. If you have any questions, please call DPS office at 313-563-9774.
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50. Submit

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