4617 Mail Service Center, Raleigh NC 27699-4617
HISTORIC PROPERTY DAMAGE REPORT
Print out this form and fill in by hand to mail in. You may also email responses to these questions to firstname.lastname@example.org
Date, type, and name of event (i.e., tornado, flood, Hurricane Isabel, etc.) _____________________________________
Name of Property: _________________________________________________________
Address: ______________________________________ Town/City/Vicinity: _____________________ County: ______________
In in a historic district, please name: ________________________________________________
Your Name: __________________________________________________________________
Your Address (if different from above):
Are you the owner of the property? ___yes ___no.
If you are not the owner, please describe your relationship to the
property and its owner:
What kind of damage did the building(s) sustain?
Will all of your damage be covered by your insurance?
If not, approximately how much money do you estimate that you will have to spend out-of-pocket to repair the damage?
Can the State Historic Preservation Office be of some assistance to you in assessing damage and advising you on restoration and repairs?
Please send this form to the address below by mail or fax. If you prefer to e-mail your responses, please do so to email@example.com.
Restoration Branch, State Historic Preservation Office
4617 Mail Service Center
Raleigh, NC 27699-4617
Greenville Office: 252-830-6580 (phone)