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Dry Basement Program Application

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Steps

1. A. DRY BASEMENT PROGRAM APPLICATION FOR REIMBURSEMENT(current) This section is complete This section is incomplete
2. B. Basement backup information (property owner complete all that apply) This section is complete This section is incomplete
3. C. Existing Condition Information This section is complete This section is incomplete

A. DRY BASEMENT PROGRAM APPLICATION FOR REIMBURSEMENT

Date*
Date
PROPERTY OWNER(S)
Property owner is the owner of record. If more than one owner's name appears on the deed, please complete all applicable fields. Property address is the location where the backup occured.
Last name (owner 1)*
First name (owner 1)*
Last name (owner 2, if applicable)
First name (owner 2, if applicable)
Other owner names, if applicable:
Property Address*
Street number and name
Full Mailing Address (if different than property address)
Street number and name, City, State, Zip
E-mail address
Phone number*
Utility bill account number
OCCUPANT OF PROPERTY (if different than property owner)
Last Name
First Name
Phone number (if known)
I, the undersigned, declare/understand:*
Please read carefully and check off all items
1. That all of the information in the application is true and that it will be subject to audit.
2. That all costs claimed herein will not be claimed for under any other insurance or assistance program.
3. If any part of this application is found to be false, the City may demand immediate repayment from the homeowner.
4. If any part of this application is found to be false, the City may avail itself of any legal remedies which it deems appropriate to recover repayment of the funds from the recipient.
Digital signature of property owner 1*
Digital signature of property owner 2
Digital signature(s) of other property owners
FOR OFFICE USE ONLY
Program application #
City lot #
PPN
Continue

B. Basement backup information (property owner complete all that apply)

1. Have you made any recent basement improvements to prevent backups?
1. Yes
2. No
2. Number of basement backups you have experienced?
3. Depth of basement backup in inches
4. Date and description of back-up(s)
5. What type of proof can you provide of the backup?
Proof will be required prior to signing an agreement.
1. Insurance claim
2. Photos
3. Statement provided at purchase
1. Home inspection report
2. Other
3. None
6. Was the backup reported to the City of Wadsworth?
1. Yes
2. No
a. Approximate date(s) when reported to City of Wadsworth
b. Was your house inspected by City employees for any of these backups?
1. Yes
2. No
c. Date of inspection and name of inspector, if known
7. Year property built
8. Number of years of residence at this dwelling
9. Have you ever received flood relief assistance from any other organization/source (i.e. your insurance company)?
1. Yes
2. No
a. If yes, specify name of organization
10. Do you have a copy of an adjuster's report or any other documentation to establish flood damage at the property?
1. Yes
2. No
11. When was the last date your sanitary lateral was cleaned?
Indicate N/A if not applicable.
Continue |Go Back

C. Existing Condition Information

1. Does your home have a:
1. Basement
2. Crawl space
3. Slab
2. If you have a basement, please check all plumbing fixtures that are present in the basement of your home.
1. Floor drain
2. Shower or tub
3. Toilet
4. Bathroom
1. Laundry sink
2. Sanitary ejector pump
3. Sump pump
4. N/A
3. If you have a sump pump, does it discharge:
1. Through the curb
2. To a storm sewer
3. Front yard
1. Rear yard
2. Side yard
3. N/A
4. Where is the origin of water flowing into the home?
1. Basement wall at the floor
2. Basement wall above the floor
3. Window
4. Up through the floor
1. Up through the drain
2. Sump pump overflow
3. Garage floor drain
4. Garage entry front
1. Garage entry back
2. Garage entry side door
3. Other
4. Don't know
5. Do you have a sanitary backflow preventer?
1. Yes
2. No
3. Don't know
Brand
Model number
Who installed it?
When was it installed?
6. Are you connected to a public sanitary sewer or septic system?
1. Public sanitary
2. Septic system
3. Don't know
7. Gutters and downspouts:
a. Does your house have roof gutters?
1. Yes
2. No
3. Don't know
b. If yes, are they collecting all roof water?
1. Yes
2. No
3. Don't know
c. How many downspouts does your house have?
d. Where do they drain?
1. Yard
2. Pipe
3. Through curb
1. Other
2. Don't know
8. Lot grading:
a. Is your home in a FEMA flood plain?
1. Yes
2. No
3. Don't know
b. Has your lot ever been flooded?
1. Yes
2. No
3. Don't know
Degree of flooding
1. 0%
2. 25%
3. 50%
4. 75%
5. 100%
c. Which way does the driveway slope?
1. To the home
2. Away from the home
d. Is there any type of drainage structure in front of the garage?
1. Yes
2. No
3. Don't know
If so, is it functioning properly?
1. Yes
2. No
3. Don't know
e. Does the yard slope toward the home?
1. Yes
2. No
3. Don't know
If yes, where?
1. Front
2. Back
3. Side 1
4. Side 2
f. Is lot near:
1. Creek/ditch
2. Detention basin
3. Pond/lake
4. Wetlands
5. Large storm sewer >3 ft. in diameter
6. Not sure
g. Does your street have a curb?
1. Yes
2. No
3. Don't know
Attach up to 8 pictures, if necessary
Image 1
Image 2
Image 3
Image 4
Image 5
Image 6
Image 7
Image 8

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