Application for an Advance Against Ontario Disaster Relief Assistance for Losses and Damages

Transcription

1 Office Use Only DRC FILE NO. Application for an Advance Against Ontario Disaster Relief Assistance for Losses and Damages THUNDER BAY DISASTER RELIEF COMMITTEE If you require help or have any questions about this application, please call the Disaster Relief Committee Office at (807) 98-FLOOD ( ). Identification which verifies your address must be presented with your application. Deadline for submission of this application is July 9, 2012 at 4:30 p.m. Applications are to be submitted to the City Clerk s Office, First Floor, Thunder Bay City Hall, 500 Donald Street East, Thunder Bay, Ontario P7E 5V3. All claims are subject to audit. If a claim is found to be based on false or misleading information, an investigation will result. Name of Applicant: City, Town, Township: Name of Co-Applicant (if applicable): Mailing Address: Home Phone: Work Phone: Legal Description or Civic Address of Buildings/Property/Dwelling(s) Subject to Loss or Damage : same as mailing Identity & Address Verified

2 Application for an Advance Against Ontario Disaster Relief Assistance Page 2 of 5 If Applicable: Farm Registration # G.S.T # Tourist License # Business # P.S.T.# Non-Profit organization Type of Loss or Damage (please check) Full time permanent residence building Farm Buildings Principal Business Enterprise Building Essential Enterprise Inventory Other (describe) Essential Household Goods Essential Farm Equipment Business Enterprise \ Essential Equipment Emergency Living Expenses Description of Damage (Attach additional page if more space is required)

3 Application for an Advance Against Ontario Disaster Relief Assistance Page 3 of 5 Declaration of Applicant(s) 1. I/We have suffered uninsurable* building loss or damage to the building(s)/dwelling(s)/property described above that to the best of my/our knowledge and belief exceeds $1, in Canadian funds. (*Regarding buildings or dwellings for which insurance was not readily available). 2. I/We apply for an advance of $1,000 against any disaster assistance for loss or damage to the building(s)/dwelling(s)/property described above that may be granted under the Ontario Disaster Relief Assistance Program (ODRAP). 3. I/We apply for such advance assistance described above as the: (Please check applicable category): Registered Owner Co-registered Owner Agent of Registered Owner (authorized by written document) Tenant 4. I/We make this application on behalf of: All members of the registered owner s household (i.e. spouse, children, parents, etc.) A non-profit entity (a corporation or other legal entity which carries on activities without the purpose of gain for its members and any profit shall be used for promoting the entity s objects) A full-time or part-time small business (corporation, sole proprietorship, partnerships, etc.) A full-time or part-time farming operation A tenant with losses for personal property only

4 Application for an Advance Against Ontario Disaster Relief Assistance Page 4 of 5 5. I/We agree to provide all information and documentation required by the Disaster Relief Committee and/or the Ontario Ministry of Municipal Affairs and Housing, to assess my/our eligibility for advance assistance and to allow any representative of the Disaster Relief Committee and/or the Ontario Ministry of Municipal Affairs and Housing access to the above described building(s)/dwelling(s)/property. 6. I/We authorize any person, agency or organization, including federal, provincial or municipal government departments, to release to the Disaster Relief Committee and/or the Ontario Ministry of Municipal Affairs and Housing, or to any of its representatives, any information required for the purpose of determining or verifying eligibility for the advance assistance that I/we have applied for herein. I/We hereby acknowledge that a photocopy of this authorization shall be sufficient to allow for the release of the specific information requested. 7. I/We declare that: I/we have received assistance from the following organizations/programs/agencies (ie. Red Cross, Salvation Army, Safe Homes, etc.) OR I/we have not received assistance from the following organizations/programs/ agencies (ie. Red Cross, Salvation Army, Safe Homes, etc.) 8. I/We acknowledge and agree to the collection of personal information under the authority of ODRAP, contained in or required by this application by the Ontario Ministry of Municipal Affairs and Housing and the Disaster Relief Committee or their officers, directors, members, employees, volunteers or agents, to be used by any of these parties to verify and administer the application being made hereunder by me/us or to perform any audits required under ODRAP. Inquiries about the collection of this personal information should be directed to the Thunder Bay Disaster Relief Committee Office, at FLOOD ( ). 9. I/We acknowledge and agree that I am/we are also required to submit on or before October 31, 2012, a full and complete ODRAP Application for Assistance for Losses and Damages (the blue form) for the purpose of assessing my/our application for assistance. Failure to submit the full and complete ODRAP application (the blue form) by October 31, 2012, will result in the requirement for immediate repayment by me/us of the amount advanced. 10. I/We acknowledge and agree that the advance payment that I/we receive shall be subject to the following conditions: a) Such amount is an advance against the total amount of disaster assistance that may be granted to me/us by the Province of Ontario, or the Disaster Relief Committee as a result of my/our claim for assistance required under paragraph 9 (the blue form);

5 Application for an Advance Against Ontario Disaster Relief Assistance Page 5 of 5 b) Such advance shall be deducted from the total amount of disaster assistance as may be provided to me/us; and c) Such advance will be used by me/us for clean-up, repairs or replacements as required by the Province of Ontario and the Disaster Relief Committee to satisfy the requirements for disbursement of an advance against disaster assistance. 11. I/We acknowledge and agree that if the Disaster Relief Committee and/or the Ontario Ministry of Municipal Affairs and Housing determines that I/we do not qualify for disaster assistance in the amount $1,000, then the advance assistance provided pursuant to this application, or the applicable portion thereof, shall be repaid, as a debt due and owing to the Government of Ontario upon its demand. 12. I understand that the Disaster Relief Committee and/or the Ontario Ministry of Municipal Affairs and Housing may limit the amount of the advanced claim payment based on the initial assessment of information that I/we have provided. 13. I/We declare that the information given in this application is true, correct and complete: that I/we have not withheld any information which may have an effect on this application; and that no other person has applied, for or received advance assistance from the Disaster Relief Committee for the above described building(s)/dwelling(s)/property which I/we are the registered owner of or have an interest in. Dated at Thunder Bay, Ontario, this day of, Signature of Disaster Relief Committee Official Signature of Applicant A copy of this application will be provided to the applicant with the approved payment.