LDA FOUNDATION DISASTER GRANT APPLICATION

Pleases provide your temporary contact information:

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.)

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.

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

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. 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:

1. He or she suffered property damages as a result of the disaster.
   
   
2. A "disaster" has been declared by a governmental agency, or has been determined by the Board in accordance with the definition provided above.
   
   
3. 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.
   
   

3. Evaluation of Application and Procedures for Processing:

1. Upon receiving the application, the Fund shall determine that (1) the disaster was declared by a governmental agency, if applicable, (2) the applicant suffered damages, (3) the application form is signed by the applicant, and (4) 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.

2. 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.

3. 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.