INSTRUCTIONS: INITIAL DAMAGE ASSESSMENT - PUBLIC ASSISTANCE

A. General Information

1. DAMAGED ENTITY - The term "Damaged Entity" refers to the public entity (municipality, county government, private non-profit entity or Cherokee Indian Nation) which owns the damaged property and/or is responsible for its maintenance or upkeep. Examples of various "Damaged Entities" include the City of Lumberton, the town of Dixon or the Brunswick Electric Membership Corporation. Each "Damaged Entity" must have a separate Initial Damage Assessment -Public Assistance form on which to document its damages.

2. County - Indicate the name of the county wherein the damaged property is located or where the incident-related expense was incurred.

3. Population - Enter the population of the affected jurisdiction. This is only applicable if the jurisdiction in question is a local government entity or the Cherokee Indian Nation.

4. Annual Op Budget - The "Annual (Operating) Budget", as used here, is the cost of the "Damaged (public) Entity's" normal operating expenses (salaries, utilities, equipment maintenance, supplies, etc.) To include monies budgeted for capital projects.

5. Outstanding Debts - The term "Outstanding Debts" refers to the amount of monies allocated this fiscal year for servicing the "Damaged (public) Entity's " outstanding debt. It does not refer to the "Damaged (public) Entity's" total debt.

6. Net Budget - The "Net Budget" is equal to the "Annual Operating Budget" minus any "Outstanding Debts".

7. Incident - This term refers to the tornado, hurricane, flood, fire, chemical spill, etc., which caused the need to file the initial Damage Assessment - Public Assistance report in the first place. Simply use a check mark to designate the type of incident. If the incident was not a flood, hurricane or tornado and "other" is checked, please specify the type of incident

8. Add'l Information Source - Indicate the name and job title of the official(s) contacted for fiscal, insurance, and damage information.

9. Telephone Number - Indicate the telephone number(s) of those contacted and listed above as "Additional Information Sources".

10. Assessment Team - Indicate the last name, first initial, of those individuals responsible for conducting this Initial Damage Assessment - Public Assistance report and for reporting the damages as shown.

11. Incident Period - Indicate the date this damage assessment was conducted.

13. Page____of___ - Pages should be numbered in consecutive order with the total number of pages indicated on each page, i.e.., 1 of 5, 2 of 5, 3 of 5, etc.

B. Damage Assessment Information - Public Assistance

14. Ref. No. - The term "Ref. No." is an abbreviation for reference number. Each affected public property is to be numbered in consecutive order for ease in identification, totaling sites, facilities, etc.

15. Name/Location (street, SR, X-ROAD, etc) - Give the name of the damaged or destroyed facility as well as its site location. For example XYZ Waste Water Treatment Plant, 2.8 miles west of the Int. Of N.C. Hwy 55 and 210 on SR 2010.

16. Description of Damage - Describe the general damage incurred at the particular site identified. However, each entry should correspond to only one single category of work. Do not combine categories of work. For example, if you are documenting damages to a building, enter all damages to the building on one line. A second entry for associated debris removal should be entered on a separate line. The following are only examples and can serve as a general guide:

Category A - Emergency Debris Removal

"Wind generated building materials, trees and personal property on public property," or "rock, sand, trees, stumps, and other debris reducing waterway opening".

Category B - Emergency Protective Measures

"Search and rescue, traffic control and security: police and firemen regular and overtime pay, temporary employees, etc.," or "temporary pumps for flooding".

Category C - Roads, Signs, Bridges

"Roadway surface washed out by floodwaters," or "pavement washed out and failed, subgrade and ditches scoured," or "flood damage to road surface, culvert and ditches," or "bridge abutments undermined, wing walls and rip-rap washed out."

Category D - Water Control (Facilities)

"High water damaged levee" or "high velocity flow scoured material from behind drainage or outlet structures".

Category E - Public Buildings and Equipment

"Floodwaters deposited debris throughout interior of building", or "walls, floors, ceiling, doors, HVAC systems, wiring, plumbing, roofing, etc. damaged."

Category F - Public Utilities

"Sewer lines blocked with debris," or "electrical distribution system damaged"

Category G - Parks, Recreational Facilities, Other "Floodwaters, high winds damaged/destroyed park grasslands," or "school ballpark lights misaligned."

17. Category A - Debris Removal - Estimate, on a site by site basis, the total dollar cost to remove debris and dispose of elsewhere. Use $6.00 per cubic yard of debris to estimate cost. Hint: Calculate the amount of debris on a cubic yardage, site by site basis. The size of any one "site" is generally considered to be about all the debris, along one city block, which could be brought to the right-of-way and hauled away. Add all sites together and report on one line. Retain estimates for later use.

18. Category B - Protective Measures - Estimate the total dollar expenses incurred for labor, equipment and materials used in responding to the incident.

19. Category C - Roads, Signs, Bridges - Estimate damages, in dollars, to the damaged entity's road systems to include: pavement, subgrade, ditches, culverts, curbs, gutters, sidewalks, bridge abutments, wing walls, rip rap, signs, etc.

20. Category D - Water Control - Estimate damages, in dollars, to any flood control, drainage, and irrigation works including but not limited to: dikes, levees, drainage channels, drops, checks, siphons, flumes, gabions, and catch basins.

21. Category E - Bldgs & Equip. - Estimate, in dollars, damages to any hospitals, public libraries, penal and public welfare institutions, public colleges and universities, police and fire stations, public office buildings and recreational buildings along with related equipment, furnishings, consumable supplies, etc. This includes those privately owned, not for profit, buildings and related equipment damaged or destroyed as a result of the incident.

22. Category F - Public Utilities - Estimate, in dollars, damages incurred by municipal and county owned utilities to include electrical distribution systems (ElectriCities), water and waste water treatment facilities, sewage pump stations, wells, etc. Also obtain estimates of damages incurred by private non-profit rural electric cooperatives, telephone companies, and other large private non-profit entities.

23. Category G - Parks & Rec. & Other - Estimate, in dollars, damages incurred by municipal and county owned recreational areas and equipment to include tennis courts, ball parks, recreational parks, school stadiums (not school buildings), swimming facilities, soccer fields, etc.

24. Total Estimated Damages - Add together the amount of dollar damages or expenses incurred on each line and enter that amount here.

25. Dollar Amount Insurance Coverage - Request from the proper official(s), the dollar insurance coverage for any of the described damages. Enter this amount as indicated. If the amount of insurance coverage is unknown, enter unknown. However, continue to try and obtain the "Dollar Insurance Coverage" and report the information as it becomes available.

26. Total Estimated Unins. Loss. The "Total Estimated Uninsured Loss" is calculated by subtracting the "Dollar Insurance Coverage" from the "Total Estimated Damages".

27. Comments (note any adverse impacts due to loss) - Enter any information not heretofore disclosed, which would indicate severe impact to the community, its people, the economy, etc.

28. Total Est. Unins. Loss/Population=$____Capita - The incident's per capita impact is calculated by adding together all estimated uninsured losses and dividing by the population of the affected jurisdiction. Example: A municipality of 6,000 people suffered uninsured losses of $18,000 for debris removal, $4,000 for building damages and $21,000 for recreational and water facility damages. The per capita impact to the municipality is:

($18,000 + $4,000 + $21,000) / 6,000 people = $7.17 per person

29. Total Est. Unins. Loss/Net Budget X 100% =_______% Impact on Budget - The % impact on an affected public entity's budget is calculated by adding together all estimated uninsured losses, dividing by the net budget and multiplying the entire result by 100 per cent. Example: The total operating budget for the public entity is $5,000,000. Amount obligated for servicing debts equals $650,000. The total estimated uninsured losses were as outlined under number 28 above or $43,000. The percent impact on budget is:

($43,000 / $5,000,000 - $650,000) X 100% = 0.99%