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2. Crop Damage Survey
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone Number:
17. Crops/Commodities Affected During 2019 Growing Seaason
19. 1. Crop/Commodity:
21. 2. Crop/Commodity:
23. 3. Crop/Commodity
25. Location of Damage:
27. Acreage/Area or Amount/Units Affected:
29. Actual Loss to Date:
31. Loss percentage (%) of Normal Total Production:
33. Total Potential Loss for Growing Season:
35. Damages to Structures or Farm Infrastructure
37. Additional Comments
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39. 1. Receive an email copy of this form.
40. Email address

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41. Submit Submit and Print

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