Disaster Victim Assistance
Onsite Septic System Repair/Replacement 
MOBILE PHONE:
HOME PHONE:
EMAIL ADDRESS:
, Alabama
ZIP CODE:
PLEASE SELECT ONE:
HOW MANY PEOPLE CURRENTLY LIVE IN THE HOME?
DO ANY DISABLED INDIVIDUALS LIVE IN THE HOME?
HOW MANY?
COUNTY HEALTH DEPARTMENT JURISDICTION:
ADDRESS:
WILL HOMEOWNERS INSURANCE COVER ANY PORTION OF REPAIR / REPLACEMENT?
CITY:
DO YOU OWN THIS HOME? 
DO YOU HAVE HOMEOWNERS INSURANCE ON HOME?
IF NO, WHO IS THE CURRENT PROPERTY OWNER?
PLEASE EXPLAIN:
ARE YOU A VETERAN?
PLEASE LIST ANY GOVERNMENT ASSISTANCE RECEIVED:
REPAIR / REPLACEMENT RECCOMENDED BY:
PHONE NUMBER:
EMAIL ADDRESS:
PERSON REQUESTING SYSTEM SIGNATURE:
DATE:
HEAD OF HOUSEHOLD NAME:
TYPE OF ASSISTANCE NEEDED:
HOUSEMOBILE HOME
YESNO
YESNO
YESNO
YESNO
YESNO