Mitigation Interest Survey
Local Government or Organization
Local Government or Organization Name
____________________________________________________
Mailing Address _____________________________________
City _________________________ State ____________ Zip ____________
Phone _______________________ Cell _________________________
Email Address _____________________________________________
Project Address _____________________________________________
City _________________________ State ___________ Zip _____________
Parcel Number __________________________________
Brief Description of Past Disaster Impacts _______________________________
____________________________________________________________________
____________________________________________________________________
List Project type _____________________________________________________
____________________________________________________________________
Has your organization participated in mitigation programs in the past for the
property seeking mitigation funding? Yes ______ No _______
Potential Grant Program _________________________________
Does the organization have Flood Insurance? Yes ______ No ______
(to be completed by EMA Planning & Grants Division Manager)