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Embed code for: Property Owner Approval-test
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Assessor Tracking Number (Office Use) Phone # Date Assessed
SOUTHERN BAPTIST DISASTER RELIEF – REGION 3
Arkansas, Texas-TBM, Texas-SBTC, Missouri, Louisiana, Oklahoma, Mississippi
PROPERTY OWNER’S REQUEST FOR ASSISTANCE
THIS IS NOT A CONTRACT TO PROVIDE SERVICES
Chainsaw Mudout Temporary Roof Ashout Heavy Equipment Attach Assessment sheet for each item of “Work Needed”, except Heavy Equipment
Boxes Chaplain Debris Removal Other
Operations - Attach Work Request Summary Sheet if more than one “Work Needed” item checked
Property Owner’s Name Property Type Single Family Multi Family Apartment/Commercial Work Location Address (Number & Street) City, State, Zip) Occupant Name (If different than owner) Occupant Status: Own Rent Guest County/ Parrish/Area GPS Latitude Coordinates: GPS Longitude Phone (H) (W) (C) Special Needs : Hearing Impaired Visually Impaired Mentally Challenged First Responder Wheelchair Health Issues Other (Explain Below) Property Insurance Home Owners Flood Can Work be done without Property Owner Present? YES NO Home Owner Permission to take Photos of Property and damage? YES NO Electricity is ON OFF
Water is ON OFF Gas is ON OFF RELEASE (Must be signed before work begins)
I, (Print Name) hereby release from liability and agree to hold harmless the Southern Baptist Convention Disaster Relief Volunteers, their representatives, agents and or employees for any damage or injury that may occur on my property, including personal property or to my person, which may occur during the cleanup operation. I further understand and agree that there is no warranty, implied, written or oral, for any work performed on my property by said volunteers. I understand that the Southern Baptist Disaster Relief is a volunteer organization that has limited volunteers, limited financial and material resources, and makes no guarantee that said service will be provided. Additionally, I further understand THAT THIS IS NOT A CONTRACT TO PROVIDE SERVICES!
Property Owner’s Signature Date
Blue Cap should Sign Summary Sheet if more than one (1) Work Needed Item Checked
Work Completed By (Blue Cap) Date Completed
SB DR R3 FORM 06/02/2014