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Dry Basement Program Application
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Steps
1.
A. DRY BASEMENT PROGRAM APPLICATION FOR REIMBURSEMENT
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. 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
That all of the information in the application is true and that it will be subject to audit.
That all costs claimed herein will not be claimed for under any other insurance or assistance program.
If any part of this application is found to be false, the City may demand immediate repayment from the homeowner.
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
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B. Basement backup information (property owner complete all that apply)
1. Have you made any recent basement improvements to prevent backups?
Yes
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.
Insurance claim
Photos
Statement provided at purchase
Home inspection report
Other
None
6. Was the backup reported to the City of Wadsworth?
Yes
No
a. Approximate date(s) when reported to City of Wadsworth
b. Was your house inspected by City employees for any of these backups?
Yes
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)?
Yes
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?
Yes
No
11. When was the last date your sanitary lateral was cleaned?
Indicate N/A if not applicable.
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C. Existing Condition Information
1. Does your home have a:
Basement
Crawl space
Slab
2. If you have a basement, please check all plumbing fixtures that are present in the basement of your home.
Floor drain
Shower or tub
Toilet
Bathroom
Laundry sink
Sanitary ejector pump
Sump pump
N/A
3. If you have a sump pump, does it discharge:
Through the curb
To a storm sewer
Front yard
Rear yard
Side yard
N/A
4. Where is the origin of water flowing into the home?
Basement wall at the floor
Basement wall above the floor
Window
Up through the floor
Up through the drain
Sump pump overflow
Garage floor drain
Garage entry front
Garage entry back
Garage entry side door
Other
Don't know
5. Do you have a sanitary backflow preventer?
Yes
No
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?
Public sanitary
Septic system
Don't know
7. Gutters and downspouts:
a. Does your house have roof gutters?
Yes
No
Don't know
b. If yes, are they collecting all roof water?
Yes
No
Don't know
c. How many downspouts does your house have?
d. Where do they drain?
Yard
Pipe
Through curb
Other
Don't know
8. Lot grading:
a. Is your home in a FEMA flood plain?
Yes
No
Don't know
b. Has your lot ever been flooded?
Yes
No
Don't know
Degree of flooding
0%
25%
50%
75%
100%
c. Which way does the driveway slope?
To the home
Away from the home
d. Is there any type of drainage structure in front of the garage?
Yes
No
Don't know
If so, is it functioning properly?
Yes
No
Don't know
e. Does the yard slope toward the home?
Yes
No
Don't know
If yes, where?
Front
Back
Side 1
Side 2
f. Is lot near:
Creek/ditch
Detention basin
Pond/lake
Wetlands
Large storm sewer >3 ft. in diameter
Not sure
g. Does your street have a curb?
Yes
No
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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