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

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SBA Form 987 (XX-XX) Previous edition is obsolete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