City of Rancho Palos Verdes

2. 
4. RESIDENT IMPACT FORM

   If you are a Rancho Palos Verdes resident impacted by the electricity shutoffs occurring since September 1, 2024, please fill out this form. The form is being used to understand the impacts and needs of the community. While filling out this form does not guarantee any support or assistance, it will help the City speak to the community’s needs and connect residents to resources, if and when they become available.

6. 1. Household Address
8. Household Address:
10. 2. Point of Contact for the Household?
12. Full Name:
14. Telephone:
16. Email:
18. 3. Do you have renter’s or homeowners’ insurance on the impacted house?
20. 1. Yes
    2. No
22. 4. Number of people in the household?
24. Number of people in the household?
26. Number of people with additional medical or functional needs
28. Number of students
30. 5. Animals in household?
32. Number of small animals
34. Number of horses
36. Number of other large animals
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field