Name:
*
First Name
Last Name
Email:
*
Phone:
*
(###)
###
####
L.A. County Badge ID Number:
*
Insurance Company and Claim Number:
L.A. County Relief Claim Number:
Current Home Address:
*
Address of home affected by the fire:
*
Date of Birth:
*
Gender:
*
Male
Female
Non-Binary
Decline to State
Please provide any other loss of personal property (e.g. automobiles, household contents, etc.).
*
If no additional damage or loss of personal property, please put N/A.
What is your level of impact on your living situation due to the fires?:
*
* Please check all that apply.
What were/are your impacts and disruptions?
*
Please check all the boxes that apply that best describe the inconveniences you have experienced.
Please provide details about any of the above boxes that you checked.
*
If you were impacted in some other way, please explain:
What are your needs and what assistance would be beneficial?
*
For any box checked above, please provide details of your needs:
*
If you are in need of any other assistance not mentioned above, please explain here:
Please share your story of the fire (in less than 500 words):
*
Acknowledgment
*
By my signature, I certify that:
1. All information I have provided regarding my application for LAEPF disaster assistance is true and correct to the best of my knowledge.
2. Only one application has been submitted for my household.
3. I will return any disaster aid money I received from LAEPF if I receive insurance or other money for the same loss or if I do not use the LAEPF disaster aid money for the purpose for which it was intended.
4. I understand that if I intentionally make false statements or conceal any information in an attempt to obtain disaster aid, it is a likely violation of federal and State laws, which can carry severe criminal and civil penalties.
5. I understand that the information provided regarding my application for LAEPF disaster assistance may be subject to sharing with various government agencies upon any future review.
6. I authorize LAEPF to verify all information given by me about my property/place of residence, income, employment and dependents to determine my eligibility for disaster assistance; and I authorize all custodians of records of my insurance, employer, any public or private entity, bank financial or credit data service to release information to LAEPF upon request.
7. I understand that any untrue statements will require me to make full restitution to LAEPF for any disaster relief grant received under this application and render me ineligible for any future LAEPF grant.
8. I authorize the grant donor to publish my submitted story and family picture(s).
Furthermore, I have read and acknowledge the following information:
Income Tax Treatment of Qualified Disaster Payments
Internal Revenue Code section 139 provides that qualified disaster relief payments from any source, including employers, reimbursing or paying individuals’ specified expenses in connection with qualified disasters are not taxable as income and are not subject to employment taxes or withholding.
A qualified disaster is defined in section 139 as a disaster that:
1. results from terrorist or military actions,
2. results from an accident involving a common carrier,
3. is a Presidentially declared disaster, or,
4. is an event that the Secretary of the Treasury determines is catastrophic.
Qualified disaster relief payments within the meaning of section 139 include payments received (regardless of the source) for the following expenses:
1. reasonable and necessary personal, family, living, or funeral expenses incurred as a result of a qualified disaster,
2. reasonable and necessary expenses incurred for the repair or rehabilitation of a personal residence due to a qualified disaster (a personal residence can be a rented residence or one you own), and,
3. reasonable and necessary expenses incurred for the repair or replacement of the contents of a personal residence due to a qualified declared disaster. Payments by a federal, state, or local government, or their agencies or instrumentalities, to persons affected by a qualified disaster in order to promote general welfare are also considered to be qualified disaster relief payments. For purposes of such payments by federal, state, or local governments, a qualified disaster includes the events listed above, as well as a disaster determined by a federal, state, or local authority to warrant governmental assistance.
Qualified disaster relief payments do not include:
1. payments for expenses otherwise paid for by insurance or other reimbursements, or,
2. income replacement payments, such as payments of lost wages, lost business income, or unemployment compensation.
