Form SBA FORM 987 SBA FORM 987 DISASTER SURVEY WORKSHEET

OMB Approval No. 3245-0136
Expiration Date: xx/xx/xxxx
Purpose of form: This form is for use by SBA's Office of Disaster Assistance only 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

Type and Cause of Disaster

Date(s) of occurrence

County or Political Subdivision Surveyed

SBA Survey Team Member(s)

Date of Request

Date(s) of Survey

DAMAGE SUMMARY
Estimated Properties Affected
Number

Homes
$ 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

Disapprove

Approve

FOC Director's Signature

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 (xx-12)

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