LDA FOUNDATION DISASTER GRANT APPLICATION

7833 Office Park Blvd., Baton Rouge, LA 70809

www.ladental.org

GRANT APPLICATION FOR LOUISIANA DENTISTS AFFECTED BY DISASTER
(for property damage only)

Application deadline: The end of the period of time in which a State of Emergency related to the disaster is declared to be in effect by the state of Louisiana.

This online application will be submitted automatically once you complete all 4 pages.
Fax additional documentation to 225-926-1886 or E-mail to tisha@ladental.org

Name

Louisiana Component (if applicable)

ADA # (if applicable)

Office Address

City

State

Zip

Do you rent or own this office? Own Rent

Are you an associate here? Yes No

Is the office on the first floor? Yes No

Did you have flooding? Yes No

Home Address

City

State

Zip

Do you rent or own your home? Own Rent

Telephone (Home)

Telephone (Office)

Pleases provide your temporary contact information:

Address

City

State

Zip

Telephone/Cell

Email

DATE OF THE DISASTER

NAME OF THE DISASTER

Briefly describe the nature of the disaster and provide documentation of the property damaged sustained. This is to help us verify an approximate dollar value for losses you suffered as a direct result of the disaster. Documentation can include photos, an adjustor’s report, a detailed description of the items damaged/lost/destroyed or a combination. (Attach additional sheet if necessary.)

Briefly describe how you plan to use emergency funds (attach additional sheet if necessary).

(PAGE 2 OF 4)

Do you have property insurance coverage for your practice facility? Yes No

What is your property deductible? $

Do you have flood insurance coverage for your practice facility? Yes No

What is your flood deductible? $

(1) What is the net loss AFTER insurance coverage on your practice facility? $

If your net loss does not equal your deductible(s), please explain why.

Do you have property insurance coverage for your home? Yes No

What is your property deductible? $

Do you have flood insurance coverage for your home? Yes No

What is your flood deductible? $

(2) What is the net loss AFTER insurance coverage on your home? $

If your net loss does not equal your deductible(s), please explain why.

What is your total property loss (line 1 plus line 2 from above)

What is your estimate of your TOTAL loss in this disaster (lost income and property damages)?
(YOU MUST FILL THIS IN WITH AN ESTIMATE!)

Of this amount what % is from income lost?

What is the % from property damage?

Your total loss multiplied by your % of property damage must equal Line 1 plus Line 2.

PLEASE MAKE SURE THAT THE TOTAL PROPERTY DAMAGE STATED HERE IS DOCUMENTED IN SOME WAY
(i.e., description on page 1, photos, adjusters report, etc.)

(PAGE 3 OF 4)

Please list the amount of any funds received to date from FEMA, Red Cross, etc. $

If applicable, please list any restrictions FEMA, Red Cross, etc. placed on your use of these funds.

Please list the amount of any funds received to date from your insurance company. $

If applicable, please list any restrictions your insurance company placed on your use of these funds.

What is your approximate net worth (pre-disaster)? $

Please indicate the nature of all your assets (stocks, savings accounts, property, etc.) and whether it is viable to use them to defray the costs you expect to incur as a result of this disaster.

Have you been able to return to work? Yes No

If so, when?

If working, is your patient load less than normal? Yes No

If so, what % of your regular patient load are you seeing now?

Do you have business interruption insurance? Yes No

How is it helping?

Certification by Applicant

I certify that I have suffered a disaster to my dental practice and/or residence as stated in this application.
I certify that the information contained in this application is true and complete. I understand that a fraudulent representation or omission of any information requested is grounds for immediate refusal to grant assistance under this program.
I understand that the granting of such assistance is neither a right nor entitlement and that the Board of Directors of the LDA Foundation shall have sole discretion in determining whether I qualify for assistance.

AMOUNT REQUESTED (Maximum $1,500) $

Signed (Please type your full name)
This serves as your digital signature.

Date Signed

Affirmation/Approval

This is to verify that the applicant named herein is a Louisiana dentist who has suffered a disaster and that the information contained herein is true and complete to the best knowledge of the undersigned. The application is thereby approved upon signature by both officials indicated below.

________________________________________________________ Date______________
Executive Director/Designated Officer, Louisiana Dental Association

________________________________________________________ Date _______________
President of the Louisiana Dental Association Foundation

LDA Foundation
7833 Office Park Blvd, Baton Rouge, LA 70809
Phone: 225-926-1986 or 1-800-388-6642
Fax: 225-926-1886
Email: tisha@ladental.org

(PAGE 4 OF 4)

IMPORTANT:
To complete your application, you must hit SUBMIT at the end of this page.

LDA Disaster Grant Rules As Amended

L. Grants to Dentists Affected by Disasters

1. Purpose: The purpose of disaster grants is to provide a small measure of immediate financial assistance to needy eligible beneficiaries who are victims of a disaster. A disaster shall be defined in the same manner as by the ADA Foundation for similar grants, and can be both natural and caused by human conduct. Examples include, but are not necessarily limited to: civil disorders (excluding acts of war), explosions, fires, tornadoes, earthquakes, floods, tidal waves, forest fires and hurricanes.

2. Eligible Beneficiaries: Any Louisiana dentist who is a victim of a disaster may apply for a grant, provided that:

He or she suffered property damages as a result of the disaster.
A "disaster" has been declared by a governmental agency, or has been determined by the Board in accordance with the definition provided above.
Application is made using the LDA Disaster Grant form during the period of time in which a State of Emergency related to that disaster is declared to be in effect by the State of Louisiana, or within 3 months of the occurrence of the disaster, whichever occurs at the later point in time.
The dentist has not applied for an ADA Disaster Grant for Dentists in the previous 10 days.

3. Evaluation of Application and Procedures for Processing:

Upon receiving the application, the Fund shall determine that (1) a disaster did occur under the definition provided by the ADA Foundation and in these Rules, (2) the disaster was declared by a governmental agency, if applicable, (3) the applicant suffered damages, (4) the application form is signed by the applicant, and (5) the damages appear to be commensurate with the requested claim. This may require, for example, a visual inspection by an investigator or a copy of an insurance claim report.
The Fund shall also verify that the application was submitted within the appropriate time frame, in accordance with section 2.c. Should a deadline date be published, reported or otherwise disseminated that does not accurately coincide with the lifting of the state of emergency or three months from the date of the actual disaster, applications will nonetheless be evaluated for timely submission solely on the basis of the actual deadline as stated in section 2.c., and it will be the obligation of the applicant to ensure submission is prior to the actual deadline rather than any deadline mistakenly or erroneously communicated by any party.
Assuming affirmation that the application satisfies all criteria under 3.a. and 3.b, it may be approved by the Fund’s Administrative Officer and Executive Director for an amount, up to the maximum allowable, that is consistent with the damages suffered and financial impact on the applicant attributable to the disaster. Applications not satisfying all criteria under 3.a. and 3.b. must be approved by the Board of Trustees.

4. Term and Amount of Grant: Grants for disaster assistance shall be offered only once per applicant per disaster as defined in these Rules, and shall not exceed $1,500.

7833 Office Park Blvd., Baton Rouge, LA 70809

We are sorry to hear about the damages sustained. We have received your grant application and will be in touch as soon as possible. Until then, should you have other questions or needs, contact us at info@ladental.org, (225) 926-1986, (800) 388-6642, or www.ladental.org.