NB. This is a sample copy of the form which is available to collect at O'Donovan's Hotel, Pearse Street, Clonakilty
...............................................................................................................
Clonakilty Flood Relief Fund
Administered by a Voluntary Committee made up of
one representative each from the Clonakilty branches of:
Personal details:
Name:____________________________________________________________________
Address:__________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Telephone Number: _____________________ Mobile:__________________________
If flooding forced you to vacate your home, please provide details of an alternative address
for the purpose of correspondence
Address:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Telephone Number(s): ______________________________________________________
Date on which your home was flooded: ___/___/___
Please give details of the extent and nature of damage to your home:
____________________________________________________________________________
____________________________________________________________________________
(Continue next page is necessary)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please enclose or include any other relevant information/documentation that you wish to provide
in support of your application:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Have you applied for other any other source of funding – State or Voluntary?
(If yes please give details, and if you have received any funding from these sources already,
please state amount):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you been accessed by your insurer(s):
_______________________________________________________________________________
Please read and sign the Declaration on next page.
Otherwise your application will not be considered
CONFIDENTIALITY AGREEMENT AND CONSENT:
All the information on this application form will be treated in the strictest confidence. However, it may be necessary for our assessors to verify or share this information or details relating to the financial relief provided to you with agencies such as insurance companies, Community Welfare Services, Local Councils / Authorities etc.
In order to process your claim as quickly as possible, please read and sign the following statement:
“I submit this application having answered all sections of the above form honestly and to the best of my ability based on information available to me on the date below.
I, the undersigned, hereby consent to Clonakilty Flood Relief assessors holding, verifying and otherwise processing personal information given on this application form with the appropriate agencies and sources as deemed necessary to complete the processing of my application for flood relief and/or made pursuant to any legal obligation of the Clonakilty Flood Relief Committee. I further consent to the Clonakilty Floor Relief Committee processing and disclosing details of my application and any financial relief made available to me to other parties including insurance companies, Community Welfare Services, Local Councils / Authorities etc. as requested, to facilitate further processing of any claims for flood relief.”
Signature: _______________________________________________
Date: ___________________________________________________
Please return this completed form in a sealed envelope, clearly marked,
“CLONAKILTY FLOOD RELIEF HOME FUND” and drop in or post to:
O’ Donovan’s Hotel, Pearse St., Clonakilty.
(Please note that form will NOT be collected from you)
Submitting an Application is not a guarantee of funding
Please note that the Closing Date for all applications is Friday 31st of August 2012
For Office Use Only
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Verified by external agency: Yes No Name of Agency: __________________________________
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Application approved: Yes No Date Payment Made: ___/___/___ Payment Amount: €_____________
Payment Ref: ____________________________