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2. Name
   First Last
3. Phone Number
   (xxx)xxx-xxxx
4. Alternate Phone Number
   (xxx)xxx-xxxx
6. Address
   Street Address
7. City
8. Zip Code
10. Email Address
12. 1. Do you own the home or are you a renter in this home?*

    1. Home Owner
    2. Renter
14. 2. Is the home owner-occupied?*

    1. Yes
    2. No
16. 3. Is the home a single-family dwelling?*

    1. Yes
    2. No
18. 4. In the past year, have you enrolled in this program for any other properties that you own?

    1. Yes (if yes, provide address of property below)
    2. No (if no, continue to 5)
20. Street address of previously SFCP enrolled property
22. 5. Did you have basement flooding?*

    1. Yes (if yes, continue below)
    2. No (if no, continue to 6)
24. 5a. How much water did you have in your basement?
26. 5b. Approximately how many times has this basement flooded?
28. 5c. During what year or years did the basement flooding occur?
30. 5d. When was the most recent time that you experienced basement flooding?
32. 5e. Did the water go away on its own?

    1. Yes
    2. No
34. 5f. Did you have property damage?

    1. Yes (if yes, complete 5g and 5h)
    2. No (if no, continue to 5i)
36. 5g. If yes, what was damaged?
38. 5h. If you had property damage, do you have photos of or receipts from the damage?

    1. Yes
    2. No
40. 5i. Have you ever filed a claim with the City for basement flooding?

    1. Yes
    2. No
42. 5j. Have you ever contacted the City with regard to basement flooding?

    1. Yes (if yes, complete 5k)
    2. No (if no, continue to 5l)
44. 5k. If yes, what did the City do to assist you?
46. 5l. Have you taken any steps to prevent future basement flooding?

    1. Yes (if yes, complete 5m)
    2. No (if no, continue to 5n)
48. 5m. If yes, what steps have you taken?
50. 5n. Do you know if your neighbors have experienced basement flooding?

    1. Yes (if yes, complete 5o)
    2. No (if no, continue to 6)
52. 5o. If yes, please describe the severity of your neighbor's basement flooding.
54. 6. Have you experienced yard flooding?

    1. Yes (if yes, complete 6a)
    2. No (if no, continue to 7)
56. 6a. If yes, how much water did you have?
58. 6b. Approximately how many times has your yard flooding occured?
60. 6c. During what year or years did the yard flooding occur?
62. 6d. When was the last time you experienced yard flooding?
64. 6e. Did the water go away on its own?

    1. Yes
    2. No
66. 6f. Did you have property damage?

    1. Yes (if yes, complete 6g)
    2. No (if no, continue to 6i)
68. 6g. If yes, what was damaged?
70. 6h. Do you have photos of or receipts from previous damage?

    1. Yes
    2. No
72. 6i. Did you ever have basement flooding from yard water coming through your basement windows, basement door, hatch or similar openings?

    1. Yes (if yes, complete 6j)
    2. No (if no, continue to 6k)
74. 6j. If yes, please explain what happened.
76. 6k. Have you ever filed a claim with the City for yard flooding?

    1. Yes
    2. No
78. 6l. Have you ever contacted the City with regard to the yard flooding?

    1. Yes (if yes, complete 6m)
    2. No (if no, continue to 6n)
80. 6m. If yes, what did the City do to assist you?
82. 6n. Have you taken any steps to prevent future yard flooding?

    1. Yes (if yes, complete 6o)
    2. No (if no, continue to 6p)
84. 6o. If yes, what steps have you taken to prevent yard flooding?
86. 6p. Do you know if your neighbors have experienced yard flooding too?

    1. Yes (if yes, complete 6q)
    2. No (if no, continue to 7)
88. 6q. If yes, please describe the severity of their yard flooding
90. 7. To the best of your knowledge, do you share a common building sewer with other homeowners?

    1. Yes
    2. No
    3. Unknown
92. 8. Are you willing and able to attend one (1) Stormwater Flood Control Program Orientation meeting?

    1. Yes
    2. No
94. 9. Are you willing and able to attend a second (2nd) Stormwater Flood Control Program meeting if necessary?

    1. Yes
    2. No
96. 10. What times and/or days are most convenient for you to attend the Orientation meeting?
98. 11. To the best of your knowledge, does your home currently have a backwater valve installed in your building sewer drain system?

    1. Yes
    2. No
    3. Unknown
100. 12. To the best of your knowledge, has your home ever been the recipient of a City sponsored backwater valve or sump pump program?

     1. Yes
     2. No
     3. Unsure
102. By entering your name below you verify that the above questionaire is filled out truthfully and to the best of your knowledge.
104. Name
105. Date
Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit Submit and Print

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