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 used by SBA's Office of Disaster Assistance only to record information collected from individuals, businesses and government officials regarding disaster related damages.
The information helps SBA to determine whether or not to issue a disaster declaration.

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
Homes
Businesses / Non-Profits
Number

$ Amount

Number

$ Amount

Major

Majors Damage Qualifying for SBA
$ Amount
Number
Homes
Businesses /
Non-Profits

Minor
TOTALS

TOTALS

Comments:

Approve

FOC Recommendation
FOC Director's Signature

Disapprove

____________________________ Date: ___________________

PLEASE NOTE: The estimated burden for completing this form is 5 minutes. 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SBA Form 987 (XX-XX) Previous edition is obsolete

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Field Worksheet For Individuals and Businesses Meeting 40% Uninsured Loss

ADDRESS

TYPE

REPLACEMENT
LOSS AMOUNT
VALUE

INSURANCE
AMOUNT

UNINSURED LOSS
AMOUNT

PERCENTAGE

HO HOME OWNERS
* Types: HO=Homeowners, HR=Home Renter, MH=Manufactured Home, BO=Business (Owns Premises) BR=Business (Rents or
Lease Premise), NP = Non Profit

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