Form SBA Form 987 SBA Form 987 Disaster Survey Worksheet

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Overview

Front
Back

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Sheet 1: Front

OMB Approval No. 3245-0136

Expiration Date: xx/xx/xxxx

Purpose of form: Used by Disaster Assistance to record information regarding disaster damage

U. S. SMALL BUSINESS ADMINISTRATION

Disaster Survey Worksheet

Disaster Assistance - Field Operations Center (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

Major Damage Qualifying for SBA Purposes

Homes

Businesses/Non-Profit

Number

$ Amount

Number

$ Amount

Number

$ Amount

Homes

Majors

Business

Minors

Non-Profit

TOTALS

TOTALS

Comments:

FOC Recommendation

Approve

Disapprove

FOC Director's Signature

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 (12/09)

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Sheet 2: Back

Field Worksheet For Individuals and Businesses Meeting 40% Uninsured Loss Criteria
ADDRESS	TYPE	REPLACEMENT	LOSS	INSURANCE	UNINSURED LOSS
		VALUE	AMOUNT	AMOUNT	AMOUNT	PERCENTAGE
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
					$0	#DIV/0!
* Types: HO=Homeowners, HR=Home Renter, MH=Manufactured Home, BO=Business (Owns Premises) BR=Business (Rents or
Lease Premise), NP = Non Profit