Property Owner Questionnaire II

Name:

Social Security #:

Telephone:
Day:

Evening:

Name:

Social Security #:

Telephone:
Day:

Evening:

Address of Damaged Property:



Mailing Address:



If you have already decided that you do not want to sell your property and do not intend to change your 
mind, check this box 0 and stop here.
How many bedrooms does your property have?

How many people live(d) there?

Do you have a mortgage?
0
Yes
0
No
How much is your monthly payment?
$

How long have you lived at the property?

Year(s)

Month(s)
If you no longer live at the damaged property, what date did you move?

National Flood Insurance Program (NFIP) Information
Policy #:

5-digit Company Code:

Agent’s Name:

Telephone:

Have you made any repairs to your damaged property?
0
Yes
0
No
Please describe any repairs made:



Have you applied for or received any NFIP settlements for your real property?
0
Yes
0
No
Amount of NFIP settlements applied for or received:
$





Other Federal and Non-federal Assistance
Please indicate any other assistance that you have applied for or received.  Where applicable, indicate 
the amount received.  (Check boxes under either “applied” or “received,” as appropriate.)

Applied
Received

Amount
Disaster Housing Program Grant
0
0
$

State Individual & Family Grant (IFG)
0
0
$

Hazard Minimization Grant
0
0
$

Small Business Administration (SBA) Loan
0
0
$

Other:


0
0
$



Save all of your receipts.

Do tenants live in this property?  Yes 0 No 0
If yes, please identify them below.




















Thank you for taking the time to provide this information.
Form II-5, Property Owner Questionnaire II
Page 2 of 2
Tool RF II-6