AAD Disaster Fund
Dermatologist Application for Relief from Oklahoma Tornado
(not Residents)
Eligibility: The American Academy of Dermatology will provide relief to its members who meet the following criteria:
· live in the area affected by the May 20 Oklahoma tornado;
· have sustained financial losses because of the physical damage to their property that are not covered by insurance, other forms of financial assistance, or other financial resources available to the applicant; and
· are members in good standing of the AAD.
The relief will be offered in the form of a low-interest demand loan with a rate not to exceed 3 percent per year, for no longer than a two-year term, and for an amount not to exceed $25,000.
Confidentiality: All of the information provided on this form will remain confidential.
Disbursement of Funds: In order to provide a reasonably equitable distribution of available funds, assistance will be provided to eligible members on a first-come, first-served basis.
Instructions: Please complete this form in full to apply for assistance from the AAD Disaster Fund. If you have any questions concerning this application, please contact the Member Resource Center at (866)503-7546.
Return the completed, signed application:
By mail to: Disaster Fund-Oklahoma Tornado
Secretary-Treasurer
American Academy of Dermatology
930 E Woodfield Road
Schaumburg, IL 60173
Or fax to: (847)240-1918
Disaster Fund-Oklahoma Tornado
Secretary-Treasurer
Finance Office
Or scan and email to:
AAD Disaster Fund-Oklahoma Tornado
Dermatologist Application for Relief
(not Residents)
(Add additional pages if necessary)
PRINT LEGIBLY
Name:______
Member Number:______
Current Mailing Address: ______
City______State______Zip______
Current Telephone: Home______
Office______
Cell______
Email Address:______
Describe the nature and the approximate financial loss you have experienced due to the May 20 Oklahoma tornado for which you are requesting assistance.
Please list the insurance companies’ names, the type of insurance (buildings, contents, etc.), and the approximate amount of insurance reimbursement you are expecting to receive and when you expect to receive it.
Please list any financial assistance you have received from other sources.
Please calculate and list below your estimated Net Financial Loss after insurance and other assistance due to the tornado.
Estimated Net Financial Loss $______
Please indicate your desired loan amount $______
Note that loan amounts cannot exceed your Net Financial Loss above or a maximum of $25,000, whichever is less.
I attest that I have answered the questions on this form truthfully and to the best of my knowledge. I further attest that I do not have access to other financial resources to cover my Net Financial Loss.
Signature ______
Date______
Thank you for completing this assistance application. You will be contacted promptly after our receipt of your application.
For Office Use Only:
Date Received ______by Mail / Fax / Email (circle one)
Approved/Disapproved By______Date ______
(circle one)
Amount Approved $______Disbursement Date ______