Montgomery County

Office of Emergency Management

Preliminary Damage Assessment

If you have suffered damages from the recent incident please fill out the damage report below. Please note that items in red are required fields.

First Name:
Last Name:
Business/Household:
Street Address:
Apartment/Unit No:
City/Town:
State:
Zip Code:
Primary Phone:
Secondary Phone:
Primary Email:
Secondary Email:
Date of Incident
Damage Type:
Type of Incident
FOR FLOOD DAMAGE ONLY (Water depth in structure)
Type of Structure
Is structure occupied?
Own or Rent
Insurance Coverage
Additional Comments

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