Flood Relief & Recovery System

Section A: Applicant Details

1. Full Name of Business Owner

2. Age

3. Gender

4. NIC Number

5. Contact Number

6. Email Address

7. Residential Address

8. GN Division / DS Division

9. Years of Business Operation

10. District

11. Family Details (Dependents)

Name	Relationship	Age	Occupation/School	Income (LKR)	Action

Section B: Business Information

12. Business Name

13. Business Address

14. Business Reg Number

Year

15. Nature of Business (Check all that apply)

Retail Wholesale Manufacturing Agriculture/Livestock Services Other

16. Main Product / Services

17. Employees Before Flood

18. Avg Monthly Turnover (LKR)

Calculated?

19. Avg Monthly Net Profit (LKR)

Calculated?

20. Business Premises

21. Any Other Properties (Movable/Immovable)

Section C: Flood Impact

22. Date of Flood Incident

23. Level of Damage

Estimated Losses (LKR)

Stock Loss

Machinery Loss

Building/Furniture Loss

Total Estimated Loss

27. Evidence Available (Check what you can provide)

Photos/Videos GN/Local Authority Report Insurance Report Disaster Management Report

Section D: Insurance & Banking

28. Was the Business Insured?

Yes No

32. Bank Name(s)

33. Existing Loans?

34. Outstanding Loan Amount (LKR)

35. Monthly Installment (LKR)

Section F: Suppliers

36. Outstanding Supplier Payment (LKR)

37. Facing Legal/Payment Pressure?

Section G, H & I: Status & Recovery

38. Current Status (Check all that apply)

Fully Closed Operation Partially Temporarily Relocated Fully Restarted

39. Current Monthly Income (LKR)

Recovery Requirements

40. Amount Required to Restart (LKR)

42. Expected Restart Timeline

41. Purpose of Funds

Stock Equipment Repairs Working Capital Loan Settlement

43. Planned Risk Reduction Steps

Relocation Elevated Storage Drainage Insurance

Section J: Declaration

I hereby declare that the information provided in this application is true and correct to the best of my knowledge. I understand that providing false information may result in the rejection of this application and legal action.

I authorize the verification of any information provided herein.

Applicant Name (Signature)

NIC Number

Date

Flood Relief Application (Form 01)