CLAIM INFORMATION SHEET

Assumption Parish Sinkhole Incident

This document is very important. If you do not complete and timely submit the information requested in
this Claim Information Sheet, your claim can NOT be timely evaluated and you wont be considered for
inclusion in the first trial setting. Please type or print legibly. When you are finished completing this
form, please sign it at the end and initial each page. A separate form must be filled out for each person.
I.

INDIVIDUAL INFORMATION
A.

Claimant Name (Full Legal Name):

____________________________ ___________________ _____________________________, __________
First
Middle
Last
Suffix

B.

Current Mailing Address (P.O.Box or Street and Number, City, State, Zip)(Where you receive your mail.)
____________________________________________
P.O. Box or Street and Number
____________________________________________
City, State, Zip

C.

Current Physical Address (Street or Road and Number, City, State, Zip)(Where you are living during the evacuation
period.)
_________________________________________________
Street or Road
_________________________________________________
City, State, Zip

II.

D.

Date of Birth: ____________

Driver's License No.: _____________ State: _____
(Attach a copy of drivers license)

E.

Social Security Number: __________________

F.

Name of Attorney: _____________________________________________________________

CLAIM INFORMATION.
A. Please list the physical address where you lived or owned property on August 3, 2012 and which was within the area
impacted by the evacuation order following the development of the sinkhole in the Bayou Corne area:
________________________________
Street or Road Name and Number
__________________________
City/State/Zip
B. Identify all structures on the property (e.g. slab-on-grade home; mobile home; travel trailer; storage shed):___________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________
Initials

C. Was this your primary residence on August 3, 2012 at the time of the evacuation order? ___Yes ___No
D. If this was your primary residence, how long had you been living at this location at the time of the evacuation on August
3, 2012? __________________
MM/YR
E. Whether the property listed in II.A. is/ was your primary residence, a property you rented or a weekend camp, have
you lived in or used the property since August 3, 2013? _______ Yes ________No
F. If yes, describe how often:___________________________________________________________________________
G. Are you currently living or using the property identified in II.A.? _______ Yes _______No
H. If this was not your primary residence, what was the physical address of your primary residence at the time of the
evacuation on August 3, 2012? _______________________________________________________
I.

Did you own the property listed in II.A at the time of the evacuation? _____ Yes __________No

J.

If you own the property, what was the date of purchase and the purchase price of your residence?
_______________________
Date of Purchase

$____________________
Purchase Price

K. Please provide the following items if you own the property:

(a) Deed to Property;
(b) Mortgage Documents;
(c) Most recent appraisal;
(d) Documents showing cost of purchase of property;
(e) Documents showing the cost of improvements to the property (including any house or other structures built on
the property)
(f) Recent (within 6-12 months) photographs showing the condition of the house and other structures before
August 3, 2012.
L. If you were living in the property identified in II.A. but were renting the property, provide the following items:
(a) A copy of your lease;
(b) The name, address and telephone number of your landlord;
(c) A cancelled check or other proof of the payment of monthly rent payments for the three (3) months, i.e. May,
June and July, 2012, before the evacuation order.
M. If you owned the property identified in II.A. but were renting it to someone else, provide the following items:
(a) A copy of your lease;
(b) The name, address and telephone number of the person to whom you were renting;
(c) A cancelled check or other proof of the payment of monthly rent payments for the three (3) months, i.e. May,
June and July, 2012, before the evacuation order.
N. Are you claiming your home sustained physical damage (e.g. broken windows, cracked slab, etc.) as a result of the
sinkhole? _________ (Yes) _______________(No)
O. If you answered Yes to N, check each item that applies:

Cracked slabs or driveways

Cracked walls, doors or windows
Subsidence of land
Changes in elevation
Movement of house
Death of vegetation
Altered drainage

_________
Initials

Gas bubbles on property

Doors or windows that no longer work
Soil contamination
Other. If other, please list and describe each other item of physical damage to your property that you are
claiming.
__________________________________________________________________________________________
__________________________________________________________________________________________

P. At the time of the evacuation, list the full name, age and relationship of each person living at the residence listed in
Section II. A. (Include your name in this list and put Self)
_________________, ___________________, _____________ ________________ ______________________
Last Name
First Name
MI
DOB
Relationship to Claimant
_________________, ___________________, _____________ ________________ ______________________
Last Name
First Name
MI
DOB
Relationship to Claimant
_________________, ___________________, _____________ ________________ ______________________
Last Name
First Name
MI
DOB
Relationship to Claimant
_________________, ___________________, _____________ ________________ ______________________
Last Name
First Name
MI
DOB
Relationship to Claimant
_________________, ___________________, _____________ ________________ ______________________
Last Name
First Name
MI
DOB
Relationship to Claimant
Q. If the evacuation order is lifted, will you move back into your property? _____ Yes _______No
R. Are you claiming any other damages (e.g. loss of income, physical, mental or bodily injury, etc.) ____Yes _______No
If yes, describe in detail what you are claiming. __________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
S. If you are claiming any other damage identified in Paragraph M, you will be required to provide additional information
related to those claims.

________________________________
Claimant (signature)

______________________________________
Claimant's Name (printed)

Sworn to and Subscribed before me, Notary, on the _______ day of _____________, 2013.

___________________
Date

______________________________
NOTARY

_________
Initials

_________
Initials