Agency Recovery Fund Application Questions

Agency Recovery Fund Application Questions

Applicant Information

Agency Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Executive Director/CEO *

Phone Number *

Email Address *

Confirm Email Address *

Program Contact *

Title *

Phone Number *

Email Address *

Confirm Email Address *

Are you United Way of Miami-Dade Impact Partner or Grantee? *

YesNo

If not, please provide the following items:

A copy of agency’s 501(c)3 IRS Determination Letter*

A copy of agency’s most recent audited financial statements*

IRS Tax Form 990*

List of agency’s Board of Directors*

Mission statement and a brief history. * (500 words max)

Insurance Coverage

Did you have insurance to cover any financial costs associated with hurricane? *

YesNo

Did you file a claim? *

YesNo

If not, why? * (250 words max)

If yes, what is the status of the claim? * (250 words max)

Please upload any relevant correspondence with your insurance provider regarding claims filed. If the damages were below the deductible level, please provide a summary of coverage. If an adjuster was hired, please provide a copy of the adjuster's contract.

Proposed Use of Funds

Describe the overall financial impact of Hurricane Irma on your agency. * (500 words max)

Please select the category(ies) that you are applying for. *

Facility Repairs

Insurance Deductible(s)

Loss of Income

Equipment Replacement/Repairs

Business Interruption

Temporary Relocation Costs

Other

Proposed Use of Funds (continued)

Please list the amount being requested by category.

Facility Repairs

Insurance Deductible(s)

Loss of Income

Equipment Replacement/Repairs

Other

Total Amount Requested *

Has your agency applied for any other disaster relief and recovery funds? *

YesNo

Other Sources of Funding Requested

Source 1 *

Amount Requested *

Status of funding *

Targeted use of funds * (250 words max)

Source 2

Amount Requested

Status of funding

Targeted use of funds (250 words max)

Source 3

Amount Requested

Status of funding

Targeted use of funds(250 words max)

Signature

Executive Director or Board Chair Signature*

*Response Required