By my signature below, I represent and confirm that each statement below is true and complete.
(3) The gallery is located in:
(4) Beginning on or about October 29, 2012, one or more of the following events have occurred solely because of the destructive impact of Hurricane Sandy (check all that apply):
Number of days business has been interrupted for.
Number of individual gallery employees payroll.
Amount of time [days, weeks, months] the gallery has in cash operating reserves.
Number of outstanding loans the gallery has.
(8) I estimate that the approximate aggregate, uninsured and unreimbursed expense associated with the foregoing events (which I will revise if/when additional information becomes known to me) is:
The figure above includes an insurance policy deductible which is not covered by any local, state or federal agency or third-party disaster relief program, of $
(9) I have (or expect to have) receipts, photographs and/or other documentary evidence to substantiate the foregoing statements and will provide this substantiation upon request.
(10) I have applied to FEMA assistance for this disaster.
(11) I understand that distributions I receive from the ADAA Relief Fund are solely for gallery restoration.
(12) I understand that ADAA will rely on these representations in determining whether and to what extent I will receive a distribution from the Hurricane Relief Fund.
(13) I understand the ADAA makes no representations as to the taxability of the distribution received.
(14) I understand that distributions from the Fund are entirely discretionary with ADAA and that I have no right to a distribution.
In consideration of being considered as a beneficiary of the Fund, I agree as follows:
- to refund to the Fund any amounts I receive from the Fund to the extent they either (i) cannot be substantiated or (ii) relate to expenses that are covered by insurance or any other third-party source of funds (e.g., relief from some other source);
- to inform designated representatives of ADAA in the event that anything changes affecting any statement contained herein.
Leaving fields blank may prevent your application from being accepted.