Economic Injury Form : Secure Forms - Cornwall NY Office of Emergency Management

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Follow listed instructions and complete requested fields

General Information

Check the box below if you are submitting updated information to a previously submitted form.

Are You Ammending A Previously Submitted Form?

Company Name

Contact Name

This form assumes address entries for Orange County, New York, all others will be rejected.

Address

Auto Completed Address:

Contact Email

Phone Number

Date of Disaster

Do You Rent or Own

Have you used savings to pay bills?

Have you taken on more debt (loans or credit card advances) to pay bills?

Have you sold any assets to pay bills?

Have you slowed, stopped or reduced payments to creditors?

Economic Injury Impact Information

If you answered NO to all questions above, please STOP and continue to the comments section. Otherwise, continue with the additional information.

Fiscal Year End

Last Year Sales

Year-To-Date Gross Sales Before Disaster

Gross Sales From Disaster Date To Now

Projected Gross Sales From Disaster Date To Fiscal Year End

Estimate Business Interruption Insurance Recovery

Estimated Date Business Will Return To Normal

Additional Information

Comments

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