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  • APPLICATION FOR DISASTER ASSISTANCE GRANT

    The deadline to submit applications for damages resulting from Hurricane Michael (October 2018, Florida) is March 31, 2019. Likewise, the deadline to submit applications for damages resulting from Hurricane Florence (Septermber 2018, Carolinas) is March 31, 2019.

    The deadline to submit applications resulting from damages from Hurricane Maria in Puerto Rico (September 2017) has closed.
     
    Please Read First:  Any AAO member who is the victim of a disaster may apply to the AAO Disaster Relief Fund for a grant to assist in restoring, repairing or reconstructing a practice facility owned by the applicant, or the dental equipment and supplies therein.  Applicants must meet the requirements prescribed in the Rules for the Disaster Assistance Program and applicants should read the Rules prior to completing this application.  The amount of the grant shall be determined at the discretion of the Fund's Board.  For a copy of the Rules, go to: https://www.aaoinfo.org/node/6553.
     
    Eligibility Requirements:  An applicant must establish that he/she suffered nonreimbursed damages to his/her practice facility from a disaster.  Further, the applicant must show that these damages have caused a serious financial hardship and that other sources of adequate funding are not available.  Replacement of lost income from practice interruption is not an eligible reason for assistance.
     
    Eligibility is determined on a case-by-case basis, and available funds will be distributed on a first-come, first-served basis.
     
  • Please explain
  • Nature And Date Of Disaster

  • Accepted file types: gif, jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, odt, avi, mov, .
    Files must be less than 2 MB.
    Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt avi mov.
  • Accepted file types: gif, jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, odt.
    Files must be less than 2 MB. Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt.
  • Accepted file types: gif, jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, odt.
    Files must be less than 2 MB.
    Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt.
  • Amount Of Damage Suffered To Practice Facility

  • Insurance Company Information

  • Certification By The Applicant

  • I certify that I suffered a disaster to my dental practice, equipment or supplies as detailed herein on this application.
     
    I intend to continue practicing in this community after this disaster.
     
    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 in this application is grounds for immediate refusal to grant any funds under this program, and is a violation of AAO ethics rules and applicable law.
     
    I understand that the granting of such funds is neither a right nor entitlement and that the Board of Directors of the AAO Disaster Relief Fund shall have sole discretion in determining whether I qualify for a grant.
     
    I hereby authorize any person, firm, corporation, agency or institution to furnish to the AAO Disaster Relief Fund any and all information in its possession relative to business of any kind whatsoever.  I certify that the financial information contained in this application to the AAO Disaster Relief Fund is true and complete. 
     
    I hereby request consideration for a disaster assistance grant not to exceed $5,000 and agree to abide by the Rules of the AAO Disaster Relief Fund.
     
  • Date Format: MM slash DD slash YYYY