Kent County Courthouse
180 Ottawa Avenue NW
Grand Rapids, MI 49503
Phone: (616) 632-5220
This form is being used for the collection of preliminary damage assessment purposes only. It is voluntary
and is for informational purposes to aid with the damage assessment effort. The information you provide will be
combined with other data and will be sent to the State of Michigan.
This form does not constitute a claim for your private insurance purposes and does not constitute an application for
assistance with any governmental agency, including FEMA.
Click Continue when you have finished adding information.
Renters: enter Zero. Owners: Enter best guess, estimating a dollar amount of structure loss.
Enter best guess, estimating the dollar value of personal property loss. This includes clothes, furnishings, vehicles, etc.
If you have insurance that covers the damage, enter the deductible. If the loss is less than the deductible, enter the LOSS (not the deductible). If you don't have insurance, put the total of the structure + property loss.
Affected: Habitable / usable; requires mostly cosmetic repairs
Minor: Not habitable / usable, but can made so in short period of time; minor repairs only
Major: 50% or more damage; not habitable / usable; requires extensive repairs
Destroyed: 100% damage; not habitable / not usable
Provide a date and brief description of relevant damages
Questions regarding this form can be directed to Jack Stewart, Emergency Management Coordinator at 616-632-6255.