SBA Form 987 Disaster Survey Worksheet

Disaster Survey Worksheet

3245-0136 987 Revised Final clearance 3-1-2021.xlsx

OMB: 3245-0136

Document [xlsx]
Download: xlsx | pdf







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 Major(s) Damage Qualifying for SBA

Homes Businesses / Non-Profits
Number $ Amount

Number $ Amount Number $ Amount Homes

Major(s)



Businesses / Non-Profits

Minor(s)



TOTALS



TOTALS

Comments:

FOC Recommendation
Approve Disapprove


FOC Director's Signature                                                                      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, RMD, 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SBA Form 987 (XX-XX) Previous edition is obsolete
Page 1
Field Worksheet For Individuals and Businesses Meeting 40% Uninsured Loss
ADDRESS TYPE REPLACEMENT VALUE LOSS AMOUNT INSURANCE AMOUNT UNINSURED LOSS
AMOUNT PERCENTAGE
















































































































































































































































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










Page 2





File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy