Application No._____________

Irish Red Cross Scheme to provide Humanitarian Support to people in Co. Donegal affected by the August 2017 Flood
from funds donated to the Irish Red Cross for this purpose

APPLICATION FORM

CLOSING DATE FOR RECEIPT OF APPLICATIONS: 30 November 2017                                  

Any discretionary contribution will be based on the amount in the fund at 30 November 2017 and the number of applicants

Part 1 – Applicant’s Details:

1.	Name of Applicant or Organisation / Business: 

___________________________________________________________________

2.	Address 		

			

3.    Flooded property address, if different to above

		

4.	Contact number  ____________________________________________________

	Email address   _____________________________________________________	

5.    Is your premises/contents currently insured against flooding risk?

YES/NO (Circle your answer)

If Yes, please detail all exclusions and information regarding any excess relating to your policy.

If No, please explain why your current policy does not have flood risk cover included?

6.    Please provide details of your current insurance policy: 

Insurance Company Name
Address 
	____________

       Policy Number

7.	Have you or your organisation / business applied for or received any other form of financial assistance in respect of the August 2017 flood damage to your premises/contents?

	YES / NO (Circle your answer)

If yes please provide details of the amount; the reason and the assisting agency or community group:

Loss and/or Damage:

8. Briefly outline the details of the damage and costs you have incurred as a result of the 
    August 2017 flood or recovery needs you require support with 

Damage/Needs	Cost of repair or recovery	

Total Cost:

Please provide more detail on extra sheet(s), if necessary.

9.   Please provide any other relevant information to your application: 

      _____________________________________________________________________

_____________________________________________________________________

_____ ________________________________________________________________

Please provide copies of any documentation or photographs you may consider relevant in support of your application.

 Declaration:

(Must be signed by the applicant)

I declare, that the information given by me in this application is correct and complete and may be retained and used by the Irish Red Cross Society for the sole purpose of determining the eligibility under this Emergency Humanitarian Support scheme for people in Donegal affected by the August 2017 flooding, funded by publicly raised monies donated to the Irish Red Cross.  The data provided may have to be verified with the relevant third parties referenced in the application. I understand and accept that these necessary enquiries are only allowable in terms of establishing and verifying the eligibility of my application under this scheme. I have read and agree with the data protection statement set out in relation to this scheme on the Irish Red Cross Website.  (https://www.redcross.ie/data-protection/)

I, therefore, authorise the Irish Red Cross Society to make all enquiries necessary but limited to establishing and/or verifying the eligibility of my application.

I undertake to provide any further information sought in connection with my application.

I undertake to advise Irish Red Cross Society immediately of any changes in circumstances which may occur affecting my eligibility for funding.

In the event that I subsequently receive any other compensation from any other source, I agree to inform the Irish Red Cross and refund such amounts of emergency humanitarian support, as may be determined refundable by the Irish Red Cross Society.  I am aware that this is a Red Cross discretionary scheme only, the criteria for which are to alleviate the needs of an individual, family, organisation or business that have emerged as a result of losses occurred in the August 2017 Donegal floods.

I AM AWARE OF THE CONTENT OF THIS APPLICATION AND I KNOWINGLY MAKE THIS DECLARATION

SIGNATURE OF APPLICANT________________________________DATE________________

CAPACITY:	(Individual/Director/Chairman/Other)

NOTE: IT IS AN OFFENCE TO GIVE FALSE OR MISLEADING INFORMATION.

INFORMATION MAY ONLY BE SHARED WITH OTHER BODIES IN ACCORDANCE WITH LAW.

Bank Transfer Payment via SEPA:

Organisation/Business/Personal Bank Account Name:

________________________________________________________________

Bank Name: ________________________________________________________________

Bank Address: ________________________________________________________________

________________________________________________________________

IBAN: ____________________________________________ 

BIC: _____________________________________________ 

I certify that this is the bank account into which the payment should be made.

Signed:

Return completed form to:

“Private and Confidential
IRC Donegal Flooding Scheme”,

Irish Red Cross,

16 Merrion Square,

Dublin 2.

Or

Email:   emergencyflooding2017@redcross.ie

For further information call:	01-6424600