Form 987 Disaster Survey Worksheet

OMB Approval No. 3245-0136

U. S. SMALL BUSINESS ADMINISTRATION
Disaster Survey Worksheet
Disaster Assistance - FOC
State

Name of Governor or Authorized Representative

Date of Request

Type and Cause of Disaster

Date(s) of occurrence

Date(s) of Survey

County or Political Subdivision Surveyed

SBA Survey Team Member(s)

DAMAGE SUMMARY
Estimated Properties Affected
Homes
Number

$ Amount

Major Damage Qualifying for SBA Purposes

Businesses/Non-Profit
Number

$ Amount

Number

$ Amount

Homes

Majors

Business

Minors

Non-Profit

TOTALS

TOTALS

Comments:

FOC Recommendation
FOC Director's Signature

Disapprove

Approve
Date

PLEASE NOTE: The estimated burden for completing this form is 5 minutes per response. You are not required to respond to any collection of information unless it displays a
current valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., SW, Washington, DC 20416 and
Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. OMB Approval
(3245-0136). PLEASE DO NOT SEND FORMS TO OMB.
SBA Form 987 (12/06)