Name of Person Completing Application *

First Name

Last Name

Personal Phone Number *

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone Number *

(###)

###

####

Was your business open to the public immediately prior to Hurricane Sandy (October 29, 2012)? *

Yes

No

Prior to Hurricane Sandy, were your annual revenues in excess of $2 million? *

Yes

No

Have you had to close your business as a result of the storm? *

Yes

No

If you have re-opened, have you been able to resume pre-storm business hours and services? *

Yes

No

Please check and fill out the below descriptions for selected items *

Repair physical damage to real property, fixtures or leasehold improvements

Repair or replace lost or damaged equipment, machinery or tools

Working capital to allow me to meet short-term financial obligations until the business can re-open (meet payroll, make business loan payments, maintain employee health insurance, etc.)

None of the Above

Did you have flood insurance at the time of Hurricane Sandy? *

Yes

No

Have you applied for FEMA or any other governmental assistance to cover the costs of repair or replacement of damage or loss incurred as a result of the hurricane? *

Yes

No

I hereby certify that the above information is true and correct, and that I have the authority to apply for the Restore Red Hook emergency grant on behalf of the above-named business. I further certify that any grant received shall be used only for the business making this application, and for the purpose stated in this application. I further certify that I do not expect that any insurance reimbursement or or any governmental assistance will cover the cost of the specific item(s) for which I am seeking an emergency grant. *

I have read the above statement and certify that the above answers are true and correct.