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Contaminated Drywall Information

If suspect that your home contains contaminated drywall, please fill out the following information. Providing this information does not guarantee that you will receive funding through the Contaminated Drywall Program, but will help us in assessing how many Louisiana citizens believe they have contaminated drywall.

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E-Mail Address*

First Name*
Last Name*
Address of Contamination*
City*
State*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*
Telephone*
Email address
Is this home part of the Road Home?*	Yes, I rebuilt with Road Home funds. No, but I purchased it with Road Home funds. No
Road Home Case No.
In what year was your home rebuilt?
RH Comments:
Has your drywall been tested for contamination?*	Yes No
Comments about testing:
How was the drywall installed?*	By a contractor As part of a self build
Name of the contractor:
If known, what company was your drywall purchased from?
Are you currently in litigation regarding your drywall?*	Yes No
Other comments?

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