Weather or Disaster Related Agricultural Damage

2. First Name*
3. Last Name*
5. Address*
6. Phone Number*
8. City*
9. State*
10. Zip Code*
12. Would you like to be contacted regarding this report?*

    1. Yes, please contact me be email.
    2. Yes, please contact me be phone.
    3. No, I do not wish to be contacted.
14. Email*
18. Damage Information
20. Type(s) of Damage (Check all that apply)*

    1. Crop Loss
    2. Farm Structures
    3. Farm Equipment
    4. Land
22. Commodity*
24. Location(s)*
26. Date or time frame where damage occurred*
28. Damage Description*
30. Total Acres Planted*
32. Estimated Percentage Loss*
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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