Glf Relief and Assistance Fund Applicatin Eligibility The Glf Relief and Assistance Fund is designed t supprt individuals wrking in the glf industry and their husehld family members wh have been impacted by a qualified disaster, beginning with Hurricane Harvey. Specifically, individuals wh derive incme n a regular fulltime r part-time basis in the glf industry (as defined in the next sentence) and their husehld family members are eligible. Fr these purpses, glf industry is defined as: Glf facilities (curses, driving ranges, etc.) Glf turnaments and events Industries that prduce gds and prvide services related t the sprt f glf, including by glf facilities and in cnnectin with glf turnaments and events. Applicants may nly apply fr supprt up t 120 days (fur mnths) fllwing the cnclusin f a qualified disaster and may submit nly ne applicatin in a given six (6) mnth perid. A qualified disaster means: a disaster that results terrrist r military actins, a disaster that results frm an accident invlving a cmmn carrier, an event that the Secretary f the Treasury determines t be catastrphic, r a Presidentially declared disaster. Types f Assistance Available The types f expenses the fund will cver include the fllwing: Living expenses (fd, rental cars, htel stays, etc.) Husing repairs (structural repairs, flring, essential furnishings and appliances, etc.) Vehicle damage Medical expenses incurred as a result f disaster (hspital stays, cunseling, rehab, etc.). See sectin tw f the applicatin fr additinal detail and examples f allwable reimbursements. Insurance cverage and ther frms f relief that an applicant may be eligible fr will be taken int cnsideratin. In additin, an applicant s financial psitin will be reviewed in mst cases, in rder t assess need. Page 1 f 7
Grants may be awarded fr mre than ne categry f lss r damage, but generally will nt exceed the maximum request amunt f $5,000. The minimum request amunt is $500. Awards are payable frm the Glf Relief and Assistance Fund, administered by Silicn Valley Cmmunity Fundatin, and will be disbursed via check t the applicant s address that is prvided belw unless therwise directed. Applicant Infrmatin All f the belw fields are *required*. I, (print yur name), respectfully request assistance frm Glf Relief and Assistance Fund at SVCF. Name f Disaster (e.g., Hurricane Harvey): Address: City: State: Email: Zip: Phne: Cunty: Withut disclsing persnal, identifying details, Silicn Valley Cmmunity Fundatin may share infrmatin abut the fund with funders and supprters, and certain funders and/r supprters may publicize awards made thrugh the fund. I acknwledge the preceding statement and certify that the infrmatin submitted is truthful and accurate t the best f my knwledge. I agree t expend the awarded grant funds fr the defined purpse and agree t refund any part f the award which is nt spent fr the defined purpses f the grant t SVCF. Signature: Date: Name f glf industry business where yu wrk: Please cmplete the rest f the applicatin and submit the cmpleted applicatin as well as all required dcuments t disasterrelief@silicnvalleycf.rg. Yur applicatin will be reviewed by an independent selectin cmmittee. Page 2 f 7
Sectin One: Eligibility There are three ptins t demnstrate that yu are, r ne f yur husehld family members is, a member f the glf industry and yu are eligible fr funding. Only ne ptin f prf is required. 1. Include the mst recent glf industry related paystub and a brief descriptin f the jb functin fr yu r the relevant husehld family member. 2. Include a signed and dated letter frm the glf industry business verifying that yu r are the relevant husehld family member is a member f the glf industry (sample language belw). 3. Yur supervisr (r whmever is mst apprpriate) in the glf industry may sign ff n the fllwing statement: I (print name), verify that (applicant name) is a member f the glf industry due t related wrk at (business name) which perates in the fllwing capacity (check ne): Glf prfessinal Glf facility maintenance wrker Hspitality and clubhuse dining staff Glf Equipment sales persn Caddie Signature: Date: Have yu applied fr funding frm the Glf Relief and Assistance Fund previusly? Yes N If yes, date f applicatin: Page 3 f 7
Financial Need We are required t btain infrmatin regarding yur financial psitin in rder t assess need. Please prvide the fllwing infrmatin: Annual husehld incme (grss): Any additinal annual nn-taxed husehld incme: Number f individuals in yur husehld: Average mnthly debt and related descriptin (e.g., student lans): Assets (e.g., apprximate value f yur hme if wned, savings, investments, etc. and a brief descriptin): Have yu applied fr emergency assistance frm ther surces such as FEMA? Yes N If applicable, hw much have yu applied fr: If applicable, hw much have yu been awarded t date: SVCF may request additinal supprt dcuments depending n yur applicatin. Page 4 f 7
Sectin Tw: Applicatin fr Supprt Please check the categry/categries f assistance yu wish t request and prvide the required prf. The applicatin will nt be accepted if required prf is nt prvided at the time f applicatin submittal. Grants may be awarded fr mre than ne categry f lss r damage, but generally will nt exceed the maximum request amunt f $5,000. The minimum ttal request amunt is $500. Yur Ttal Request Amunt: $ Categry A Living Expenses Incurred living expenses as a result f displacement (htel stay, car rental, etc.) which are nt cvered with prceeds frm an insurance plicy. Please prvide a brief descriptin f the expenses. Only list expenses that are nt cvered by insurance. Yur insurance deductible is reimbursable. Required Prf (please submit with applicatin) Receipts D yu have a current insurance plicy? Yes N If yes, please prvide a cpy and/r dcuments pertaining t a related claim. Categry B Husing Expenses Lss r damage t primary residence wned by yu and/r husehld family member. Fences, railing and/r stairs arund yur residence wuld als be cvered as wuld essential appliances r furnishings. Damage might be the result f fire, earthquake, strm surge, rising fldwaters entering the residence, high wind, water leakage r falling debris. Such lss r damage must nt be cvered with prceeds frm an insurance plicy. Page 5 f 7
Please prvide an itemized list f damages including an estimate f the mnetary lss. Only list thse expenses that are nt cvered by insurance plicies. Yur insurance deductible is reimbursable. Required Prf (please submit with applicatin) Pht Evidence, Receipts and/r Estimates D yu have a current insurance plicy? Yes N If yes, please prvide a cpy and/r dcuments pertaining t a related claim. Categry C Persnal Vehicle Lss r damage t persnal vehicle(s) wned by yu, where the ttal cst f replacement and/r repairs are nt cvered with prceeds frm an insurance plicy. Please prvide a brief descriptin f the damages, including an estimate f the mnetary lss. Include the year, make and mdel f the vehicle. Only list expenses that are nt cvered by insurance. Yur insurance deductible is reimbursable. Required Prf (please submit with applicatin) Pht Evidence, Receipts and/r Estimates D yu have a current insurance plicy? Yes N If yes, please prvide a cpy and/r dcuments pertaining t a related claim. Page 6 f 7
Categry D Medical Expenses Incurred medical expenses as a result f disaster and nt cvered with prceeds frm an insurance plicy. These may be expenses incurred by the applicant and/r a husehld member. Fr example, the fllwing expenses are acceptable: - Significant medical expenses nt eligible fr insurance reimbursement - Prescriptin medicatins nt cvered by insurance - Travel expenses related t medical care - Psychlgical cunseling fllwing the disaster, as deemed necessary by a medical prfessinal, in excess f what is cvered by insurance - Expenses related t physical rehabilitatin due t an injury frm the event nt cvered by insurance Please prvide an itemized list f expenses. Only list thse expenses that are nt cvered by insurance plicies. Yur insurance deductible is reimbursable. Required Prf (please submit with applicatin) Pht Evidence, Receipts and/r Estimates Thank yu! Thank yu fr yur applicatin t receive assistance thrugh the Glf Assistance and Relief Fund. Yur applicatin will be reviewed as sn as pssible. If awarded assistance, yu will be ntified via email and/r phne and will receive a check in the mail at the address prvided n the applicatin. Refer t www.glfrelieffund.rg fr mre infrmatin regarding timelines. Shuld yu have questins abut this applicatin, please cntact disasterrelief@silicnvalleycf.rg Page 7 f 7