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2. Residential address

   You can also find this survey form on-line at ready.maricopa.gov. Click on the Palo Verde Generating Station link and then the Evacuation Assistance link. If you have questions or would like assistance to complete this survey please contact (602) 273-1411 or TDD/TTY (602) 244-1409. 

4. Street*
6. City*
8. State*
9. Zip*

13. Names of Household Members

14. Assistance Needed

16. Total Household Members*
18. name
19. y

    1. y
21. n
22. n

    1. y
24. n
25. y

    1. y
27. n
28. n

    1. y
30. n
31. y

    1. Yes
33. y
34. y

    1. y
38. House Number
39. Cell Number
40. Text

    1. Yes
41. Text

    1. No
43. n*

    Would you or any member of your family, (including children or elderly  home unattended during the day), require evacuation transportation assistance to leave your home on short notice?

    1. Yes

    1. No
45. Do any household members utilize

    (check all that apply)

    1. Walker, Wheelchair, or Cane
    2. Life Sustaining Equipment that requires Electricity

    1. Ventilator, Respirator, or Oxygen
    2. Service Animal
47. Please check ALL that apply that best describe any disability or medical condition

    1. Deaf or Hard of Hearing Impairment
    2. Blind or Visual Impairment
    3. Non-Verbal Communication or Speech Disability
    4. Alzheimer's, Dementia, or Cognitive Disability

    1. Autism Spectrum Disorder
    2. Psychiatric Disability
    3. Siezure Disorder

49. 1. Do you have a food garden that you grow broad-leaf produce (lettuce, spinach, cabbage, etc.) that is at least 500 square feet?

50. a

    1. Yes

    1. No

52. 2. Do you have a goat or cow that you gather milk from?

53. h

    1. Yes

    1. No

55. 3. Do you have any additional animals/pets? If yes, how many?

56. h

    1. Yes

    1. No
58. dogs
59. cats
60. horses
61. other
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field