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BASTROP COMPLEX FIRE – DESTROYED STRUCTURES LIST
BASTROP COUNTY
9-1-1 Addressing & GIS Mapping
806 Water Street Bastrop, Texas 78602
OFFICE: 512/581-4242 FAX: 512/581-4241
How do I add my home/business to the Destroyed Structures List?
If the structure was a habitable
1
residence or commercial business submit a REQUEST FOR INCLUSION
form –or the information shown below, to Bastrop County at 806 Water Street, Bastrop, Texas 78602.
A signed and notarized document –printed in ink, which includes:
1) Your name, identification #, mailing address, and daytime telephone number (e-mail address optional)
2) Destroyed structure’s address
2
3) Relationship to the destroyed structure (owner or occupant)
4) Destroyed structure type (residential or commercial)
5) Destroyed structure classification (concrete (reinforced), insulated concrete form, light gauge metal,
manufactured housing, masonry (reinforced), masonry (unreinforced/plain), metal building, mobile
home, shear walls, tilt-up (concrete pre-cast), or wood frame)
6) Destroyed structure habitable area (square feet or dimension)
7) Bastrop Central Appraisal District property identification number and legal description
8) Date the destroyed structure was built or placed on the property and became habitable
9) The following statement: “I hereby request that the destroyed structure referenced in this document be
included on the Bastrop County Destroyed Structures List. I declare under penalty of perjury that
structure referenced in this document was destroyed by the Bastrop Complex fire. I hereby certify under
penalty of perjury that the information provided on this document and all attached pages are true,
correct and complete.”
10) Documentation –Provide two of the following documents (must include the destroyed structure’s address
2
):
a)
Driver's license (residential documentation only)
b)
Voter registration card (residential documentation only)
c)
W-2 (residential documentation only)
d)
Utility bill (water, electric or phone) –within 3 months prior to the fire
e)
Insurance policy (homeowner, renter, commercial or business property)
f)
Lease agreement or recent rent payment receipt –within 3 months prior to the fire
g) DECLARATION OF OCCUPANCY from the owner –printed in ink, sign, and notarized, which includes:
(i) Owner(s) name, mailing address and daytime phone number (e-mail address optional)
(ii) Tenant(s) name, mailing address and daytime phone number (e-mail address optional)
(iii) Destroyed structure’s classification and address
2
(iv) Date of occupancy
(v) The following statement: “I hereby declare under penalty of perjury that (insert tenant’s name)
occupied (insert destroyed structure’s address
2
) since (insert date of occupancy). I hereby
certify under penalty of perjury that the information on this document is true, correct and
complete.”
11) Additional information or documentation may be necessary to substantiate the claim.
1
Habitable means the structure is safe and can be occupied in reasonable comfort. It should be closed against the weather, have
heating and electricity, potable and hot water supplied through proper fixtures connected to acceptable plumbing and sewage
systems, operational bathroom and toilet facilities.
2
Complete physical address assigned by the local government agency (address #, street name, bldg/apt/unit #, city and zip code).
BASTROP COMPLEX FIRE – DESTROYED STRUCTURES LIST
BASTROP COUNTY
9-1-1 Addressing & GIS Mapping
806 Water Street Bastrop, Texas 78602
OFFICE: 512/581-4242 FAX: 512/581-4241
REQUEST FOR INCLUSION
Name: ID#:
First Name MI Last Name Suffix State Issued Driver’s License or ID #
Mailing Address:
Address # Street Name Bldg/ Apt/Unit# City State Zip Code
Daytime Telephone Number: e-mail:
(Area Code) Phone Number, Ext. e-mail Address
Destroyed Structure’s Address:
As assigned by the local govt.: Address # Street Name Bldg/ Apt/Unit# City Zip Code
Relationship to the Destroyed Structure (check one) Owner Occupant
Destroyed Structure Classification (check one): Residential Commercial
Destroyed Structure Type (check one): Concrete, Reinforced Insulated Concrete Form Light Gauge Metal
Manufactured Housing Masonry, Reinforced Masonry, Unreinforced/Plain Metal Building
Mobile Home Shear Walls Tilt-Up (Concrete Pre-cast) Wood Frame
Destroyed Structure Habitable Area: square feet -or- feet by feet
Bastrop CAD Property ID and Legal Description:
Date the destroyed structure was built or placed on the property AND became habitable:
Month Date Year
Documentation –Attach two of the following documents (must include the address
2
of the destroyed structure):
• Driver's license (residential documentation only)
• Voter registration card (residential documentation only)
• W-2 (residential documentation only)
• Utility bill (water, electric or phone) –within 3 months prior to the fire
• Insurance policy (homeowner, renter, commercial or business property)
• Lease agreement or recent rent payment receipt –within 3 months prior to the fire
• DECLARATION OF OCCUPANCY from the owner –printed in ink, sign, and notarized, which includes:
Owner(s) name, mailing address and daytime phone number (e-mail address optional)
Tenant(s) name, mailing address and daytime phone number (e-mail address optional)
Destroyed structure’s classification and address
2
Date of occupancy
The following statement: “I hereby declare under penalty of perjury that (insert tenant’s name) occupied
(insert destroyed structure’s address
2
) since (insert date of occupancy). I hereby certify under penalty of
perjury that the information on this document is true, correct and complete.”
I hereby request that the destroyed structure referenced in this document be included on the Bastrop County
Destroyed Structures List. I declare under penalty of perjury that the structure referenced in this document was
destroyed by the Bastrop Complex fire. I hereby certify under penalty of perjury that the information provided on
this document and all attached pages are true, correct and complete.
Signature Date
Acknowledgment
STATE OF TEXAS §
COUNTY OF BASTROP §
This instrument was acknowledged before me on the _____ day of ______________, 20____ by
Notary Public, State of Texas
Notary’s Name (printed):
Notary’s Commission expires:
BASTROP COMPLEX FIRE – DESTROYED STRUCTURES LIST
BASTROP COUNTY
9-1-1 Addressing & GIS Mapping
806 Water Street Bastrop, Texas 78602
OFFICE: 512/581-4242 FAX: 512/581-4241
DECLARATION OF OCCUPANCY
Owner Information
Name:
First Name MI Last Name Suffix
Business Name:
Business Name, if applicable
Mailing Address:
Address # Street Name Bldg/ Apt/Unit# City State Zip Code
Daytime Telephone Number: e-mail Address:
Telephone Number with Area Code e-mail Address (Optional)
Tenant Information
Name:
First Name MI Last Name Suffix
Business Name:
Business Name, if applicable
Mailing Address:
Address # Street Name Bldg/ Apt/Unit# City State Zip Code
Daytime Telephone Number: e-mail address:
Telephone Number with Area Code e-mail Address (Optional)
Structure Information (check one): Residential Commercial
Complete Physical Address (as assigned by the local government agency): Address # Street Name Bldg/ Apt/Unit# City Zip Code
Occupancy Date: From: To:
Month Date Year Month Date Year
I hereby declare under penalty of perjury that
Tenant’s Name
occupied
Structure’s address, as assigned by the local govt.: Address # Street Name Bldg/ Apt/Unit# City Zip Code
from: to: .
Month Date Year Month Date Year
I hereby certify under penalty of perjury that the information on this document is true, correct and complete.
Owner’s Signature Date
Acknowledgment
STATE OF TEXAS §
COUNTY OF BASTROP §
This instrument was acknowledged before me on the _____ day of ______________, 20____ by
Notary Public, State of Texas
Notary’s Name (printed):
Notary’s Commission expires:
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Completed 5 August 2020

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