LINE 1, 2 & 3 |
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Enter owner's full name, mailing address, and daytime telephone number |
LINE 4 |
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Enter registration number of damaged home. (This number is shown in your bill.) |
LINE 5 |
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Enter the full address of the damaged home. |
LINE 6 |
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Enter name of the county where damaged home is, or was, located. |
LINE 7 |
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Enter date the damage or destruction occured. |
LINE 8 |
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Explan cause of damage: Example: fire, flood, intentional demolition, etc. |
LINE 9 |
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Describe the damage to the home. Attach additional pages if necessary. |
LINE 10 |
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Enter your best estimate of the reduction in the home's value caused by the damage. |
LINE 11 |
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If home is insured, show the amount the insurance company paid or will pay if available. |