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Long Island Teochers Benevolent
_
Spccial Sandy Emergency
Fund
fi""nciaf Crant Application
The Iong Istand reac*rers Benerrolent
oftle after-effocts of 2otls,p.*i*rn_s""&is commi'tted to herp you d,rirqg yo,r time ofneed or distress
as a resutt
actral dollaramountofthegram
Fund
fu L;J;;;uer
&*#rb:itogu_
ofappricatoos'"Gra
Please read and comnlete this
G-rant Applicatiou once the entire
fofln is
please retrm the orisinal. slg"a
Fund" I 00 soua
uii"
r"tt6'yil't*l
"ra
*rao, $6ffi per appticant Thc
tuads ava,afue fordisriburion
yt *rpr*q
sigd atd nuarired,
Pn*idenG ;rl"ira"a,*
Long Isrand
-i'i**
sto""t' suit" zos' ityriul, New york
r izu.
submir
Teachers Bensvorenr
by JANUARY 25, 2013.
Certificatiou
I
your ftrll oamel have incurre4 or
will ircur, tte following
losses: (al.personar, fr-lly,ilrG
or funeral
't
expenses
)xpenses (includes temoorarv
temporarv housins
rrorrsino mtrri-r
residence or reoair or.eptt""**t;fdcontents","arJ
please note
and services cannot t" tti*ut'"sa
*a
".:l*-Y!:p
"*plrm;-ffiXrffiT#,I;ffi?,,ll,H?il
tha nonesentiat, luxrr,r, or decorarive items
pesoml
Pi;il;
More than $50'000
- ''
r
--
m"
$25'000 to $50,000
".c-",.a
---
$
a"u*
"*unt
10,000 to $24,gg
of loss by checking arnormc
_under
$
lo0@
I attest &af the losses itemized above
are attrib.frable to the stomr which
has been dectared by FEMA to be
a "qualfred disaster'- (New York Superstorm
Sandy, on<ots) (hup:1/www-femagov/disaster/40g5)I understand that although I am not required
to provide proofofac*ual exp€oses to
receive a disaster relief
grartr' the disaster relief payment
r
a,.tmt of uwe imba'sed erpenses describd r**ir,[riu.""ry*,"a b be commensurate with the
dive -*
'
"b"r;;;;,il-ia..o-
i@mized above have not been, or
wilr not be corpensded by FEMA, insurance
or
mmffi
' ffiffimffi.*'
a disaster
reliefpayment from the Fund, I am rquired
to use the palanent for
I understand that my sigrung this appticdion
does not au0omatically entitle me
to receive a disaster relief
payment I firrther understad that -itorsenatives
oftlre r*a
ru fir,nt ardronity, and have sole
disretioq in aaarnining
ot n"t I q,ali& ro. a aGter relief payrrcrt (irclding
L"
ffi;:*
"aemer
disasrcr reliefPalment
can
By signing this Apptication' I hereby
attest
"d
for tle above referenced itentzed to*ii ,ial
ui.*.i*trv rrpJ"a,"
ui
whether the
"i-*i,",*t
ttn
rhe expenses
?ff,
!: tlt Fyd tha: (a) I hove incttne{ or wlr incvr expnses
that the Fund moy rcry
apon
nq/stdenents hereiru
Sigmtrne ofApplicant
Nameoflncal Union
Signature
Address of Agpticatrt
"t*ro
s an in_service member
of l-ocal
VERIFICATION_TO BE SICNED
IN THE PRESENCE OFA NOTARY P{IBLIC
State ofNewyorlq Cormty
of
On
this_-day
of the nronth
of
DisasterTer##;dffi ion-rh"c"t""t#i|*-rr.-Trf;:ffi:'ffi
ffi
::*:"ffi .*roregoing
Applicant's Signa0re
Sworn to before nrc this
Notary public
=-
day
of.----,
20