Section XI APPENDIX and FORMS - Health NY - New 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date completed and your name in the designated fields. This ensures that your submission is properly attributed.
3. Fill in the Head of Household's last name, first name, and date of birth. If applicable, include your spouse’s information as well.
4. Provide the address of your damaged home and current contact numbers. Indicate whether you own or rent the property and confirm if it is your primary residence.
5. Complete details about your landlord if applicable, including their name, address, and phone number.
6. Specify the type of home you reside in by selecting from options such as Single Family, Duplex, or Apartment.
7. Indicate the number of people living in your home along with their respective categories: elderly, adults, disabled, and children.
8. Detail any insurance coverage you have related to homeowner's insurance or flood insurance. Include whether you've contacted your agent regarding claims.
9. Describe any damage to your home and list immediate needs for assistance such as debris removal or temporary housing.
10. Once all fields are filled out accurately, click on the 'Submit' button to return the form to the designated recipient.

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