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2. 
3. City of Nassau Bay
   Severe Winter Weather Damage Reporting Form
5. Please let us know if your home suffered damage due to the recent Arctic Blast - Winter Storm Uri.
   This form was created to assist the Nassau Bay Office of Emergency Management in determining what areas of our community experienced damage from the recent Arctic Blast - Winter Storm Uri. This form assists the City in evaluating those locations. Please DO NOT use this form to request direct assistance or disaster relief. As always, call 911 for emergency assistance.
   
   THIS FORM IS FOR INTERNAL CITY USE ONLY AND INDIVIDUAL DATA WILL NOT BE FORWARDED TO OUTSIDE PARTIES. THE AGGREGATE DATA WILL BE USED FOR EMERGENCY MANAGEMENT PLANNING PURPOSES AND GIVEN TO THE STATE FOR THE ERCOT INVESTIGATION COMMITTEE.
7. First Name*
8. Last Name*
10. Phone Number*
11. Email*
13. Physical Address that Incurred Damage*
15. Date Damage Occurred *
    Date Damage Occurred
16. HOA (if applicable)
18. Address1
20. City
21. State
22. Zip
24. Did your home lose power?

    1. Yes
    2. No
25. Did your home lose power for more than 24 hours?

    1. Yes
    2. No
27. Did your home lose water?*

    1. Yes
    2. No
28. Did your home have a water leak / break?

    1. Yes
    2. No
30. Describe your home's damage.*
32. Do you have home insurance?*
    -- Select One --YesNo
33. Do you have flood insurance?*
    -- Select One --YesNo
35. Do you own or rent your home?*
    -- Select One --OwnRent
36. If you have any photos of your damage please upload them here
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field