Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697643086265.pdf (Bahamas)
THE NATIONAL EMERGENCY MANAGEMENT AGENCY (NEMA) HURRICANE MATTHEW VERIFICATION OF DAMAGE AND REQUEST FORM FOR REPLACEMENT OF Building Materials, Electrical and Plumbing Fixtures and Materials, Household Furniture, Furnishing and Appliances, Generators PLEASE PRINT Name of Head of Household: _____________________________________________________ APPLICANT INFORMATION Name of Applicant: ________________________ / ___________________/ _______________ Last Name First Name Middle Name Marital Status: ___________________________________ Age: ___________________ National Insurance No.
: ________________________ Date of Birth: __________________ Address: ______________________________________________________________________ ______________________________________________________________________________ Island: ________________________ City/Town/Settlement: ____________________________ Postal Address: ________________ E-mail: _________________________________________ Telephone #: ________________ / _______________ / ________________ / _______________ Home Cell Work Fax Number of Person(s) in Household: ___________ Name Age Employment Status Salary Employment Status: ___________________________ Occupation:_______________________ Employer: _____________________________________________________________________ Weekly Household Income Range: (a) Under $100.00 _______________ (b) $101.00 - $200.00 ____________ (c) $201.00 - $300.00 _____________ (d) $301.00 - $400.00 ____________ (e) $401.00 - $550.00 _____________ (f) Over $550.00 ________________ Page 1 of 3 Please check applicable blocks: Type of Structure: Block/Stone Wood Stucco Tabby Extent of Damage: Slight Moderate Severe Destroyed Ownership: Owner Tenant Do you have Insurance Coverage?
Yes No Sum insured: Building _______________________ Contents __________________________ Have you made or will you make a claim for Insurance?

________________________________ Name of Insurance Company / Broker: ______________________________________________ Please attach copy of insurance settlement DETAIL OF GOODS THAT ARE BEING REQUESTED: On the attached sheet, please provide detail of each item for which approval is being sought include quantity, description and value.
Port of entry where goods will be imported: __________________________________________ ______________________________________________________________________________ Please note that where any abuse or misuse of goods imported under this Declaration is observed, the goods may be seized and disposed of in accordance with Section 268 of the Customs Management Act.

I certify that the above information that has been provided is true.
_______________________________________ ________________________ Signature of Applicant Date ______________________________________________________________________________ FOR OFFICIAL USE ONLY Certified by ______________________________________ Administrator __________________ Date Certified by _______________________________________ Director of NEMA __________________ Date Approved Denied Pending Comments: ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Process by: ___________________________ ________________________ ____________ Name (Print) Signature Date Page 2 of 3 ITEMS REQUESTED FOR DUTY FREE IMPORTATION UNDER DECLARATION OF EXIGENCY ORDER HURRICANE MATTHEW PLEASE PRINT Name of Applicant: _____________________________________________________________ Island: ______________________________ Settlement: __________________________ Quantity Description $ Value Page 3 of 3