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2. First Name
3. Last Name*
5. Address
7. City
8. State
9. Zip Code
11. Contact Person*
12. Phone Number*
14. Email Address*
16. Please designate if this issue involves:*

    1. Single owner
    2. Multiple owners

    If multiple owners are involved, please complete the contact information for each party at the end of this application.
18. Location*
20. Description of Problem*
    Attach additional documentation as needed
22. Additional Documentation
24. Verification of General Eligibility (all of the following are to be met)*

    1. Public Right-of-Way runoff must be carried
    2. The property involved in the project must be zoned residential and must be improved with by one single-family residential dwelling unit
    3. The property owner must have been issued a Village of Clemmons Stormwater Management Certificate of Occupancy for at least two years prior to the request for assistance
    4. Issue involves: flooding of a dwelling, immediate threat to structural integrity of a dwelling, severe erosion of drainageway, OR impede flow of water due to fallen brush/vegetative debris
26. Owner 2
28. Address
30. City
31. State
32. Zip Code
34. Owner 3
36. Address
38. City
39. State
40. Zip Code
42. Owner 4
44. Address
46. City
47. State
48. Zip Code
50. Owner 5
52. Address
54. City
55. State
56. Zip Code
58. Owner 6
60. Address
62. City
63. State
64. Zip Code
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field