Parker Waichman Alonso LLP | Toxic FEMA Trailers

Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
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Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Dates you lived in a FEMA trailer following Hurricane Katrina:

Do you still live in a FEMA trailer?
Yes
No

Location of FEMA trailer (State):
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Please describe illnesses you believe are from toxins such as formaldehyde in your FEMA trailer:

Have you received any medical attention for injuries from living in the FEMA trailer?
Yes
No

Have you downloaded Form 95 and mailed it to us? If not please do so immediately after filling out this online form.
Yes
No

Other Info:

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