By my signature below, I represent and confirm that each statement below is true and complete.
(1) The name of the art gallery is:

(2) The address of the gallery is:

(3) The gallery is located in:
a FEMA declared disaster area OR
Zone A

(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):
The gallery was destroyed.
The gallery was significantly damaged.
The contents of the gallery were destroyed.
The contents of the gallery were significantly damaged.
Specify loss here :


Number of days business has been interrupted for.

(5) Number of individual gallery employees payroll.

(6) Amount of time [days, weeks, months] the gallery has in cash operating reserves.

(7) 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.
Yes
No

(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:

1. 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);
   
   
2. to inform designated representatives of ADAA in the event that anything changes affecting any statement contained herein.

Name of Gallery

Name of Contact

Contact Email

Contact Phone

Date

Leaving fields blank may prevent your application from being accepted.