Free 53313.FH11 - Indiana

INDIANA DISASTER ASSISTANCE PROGRAM
State Form 53313 (6-07) INDIANA DEPARTMENT OF HOMELAND SECURITY

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Date (month, day, year) Control number E-mail address

APPLICANT INFORMATION
Title

Mr. Mrs.

Miss Name (last, first, middle) Ms.
Age Do you live in a mobile home? Sex

Is this your legal name?

Marital status

Yes Male

No

Single
Home telephone number

Married Divorced

Separated Widowed

Date of birth (month, day, year) How long have you lived at this address?

Female No

( (

) )

Cellular telephone number

Yes
Street address of damaged home (number and street, city, state, and ZIP code)

Mailing address (if different than address of damaged home) (number and street or PO box, city, state, and ZIP code) Is your house livable? Do you own or rent? Type of house

Yes

No

Own

Rent

Frame Brick

Basement Two story

Water level in your home (inches and/or feet)

Family members under eighteen (18) years of age: Name of spouse or significant other (last, first, middle) Address (if different) (number and street, city, state, and ZIP code) Date of birth (month, day, year) Other telephone number

(

)

INSURANCE INFORMATION & DAMAGES
Do you have homeowners insurance? Do you have medical insurance? (See page 2) Medical insurance company Telephone number of employer

Yes

No

Yes

No

Your occupation

Name of employer

(

)

Address of employer (number and street, city, state, and ZIP code) Do you have flood insurance? Policy Date (month, day, year)

Yes
Damaged rooms

No Kitchen Basement
Appliances damaged Application number Vehicle model Vehicle year License plate number

Finished basement
Personal property damaged

Living room Family room
Clothing

Bedroom 1 Bathroom
Medical needs

Bedroom 2 Bedroom 3 Other ___________________________________________
Transportation Type of home residence Tools

Applied for USSBA Disaster Loan?

Yes
Vehicle make

No

Primary

Vacation Lease Other ____________________
State

NAME OF OTHER ADULT LIVING WITH YOU

OTHER ADULTS IN YOUR HOUSEHOLD RELATIONSHIP TO YOU HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER

The above information is true and accurate to the best of my knowledge. I am not engaged in fraudulent conduct in this application for disaster assistance. I agree to indemnify and hold harmless the State of Indiana, as well as its agents and employees, for any claims arising from the administration of the Indiana Individual Disaster Assistance Program.
Signature Date (month, day, year)

PLEASE LIST DAMAGES IN DETAIL ON PAGE 2 OF THIS APPLICATION

DETAILED LIST OF DAMAGES
Part of State Form 53313 (6-07) Name of homeowners insurance company Address of insurance company (number and street, city, state, and ZIP code) Telephone number of insurance company

(

)

VERIFIER USE

DESCRIPTION OF ITEM

PURCHASE PRICE

QUANTITY

LOCATION

Medical

Transportation