Disaster Relief Request Form

Disaster Relief Request Form & Assistance Agreement

Requesting Party Name:    Relief Provider Name:

RECITALS

WHEREAS, the Requesting Party has suffered loss or damage arising from a declared or perceived disaster event and seeks emergency relief and recovery assistance from the Relief Provider; and

WHEREAS, the Relief Provider has the capacity to provide emergency supplies, services, technical assistance, or financial support subject to the terms set forth in this Request Form and Assistance Agreement; and

WHEREAS, the parties wish to document the requested scope of assistance, funding and reimbursement terms, confidentiality, and other administrative and legal provisions governing the provision of relief.

REQUESTOR INFORMATION

Individual    Organization    Non-profit / NGO    Government

DISASTER DETAILS

Date of Incident:    Type of Disaster:

ASSISTANCE REQUEST — SCOPE OF WORK

The Requesting Party requests the Relief Provider to furnish the following assistance. Provide a concise description of tasks, materials, quantities, and any site-specific requirements.

PAYMENT TERMS

The Relief Provider's provision of goods or services shall be subject to the following payment and funding terms. Any funding provided is subject to appropriation and approval by the Relief Provider in its sole discretion.

All disbursements are subject to verification of costs, submission of supporting documentation, and compliance with applicable procurement and recordkeeping requirements. The Requesting Party agrees to refund any amounts later determined to have been improperly paid.

TERM AND TERMINATION

This Request Form and Assistance Agreement commences on: and, unless earlier terminated in accordance with this section, will terminate on:

Either party may terminate this Agreement for convenience upon written notice to the other party delivered no fewer than days prior to the effective termination date. Termination for cause may be immediate upon written notice where a material breach remains uncured for 10 days following written demand for cure.

CONFIDENTIALITY

All non-public information exchanged in connection with this Request and Assistance Agreement that is designated confidential or that by its nature should reasonably be understood to be confidential shall be held in strict confidence by the receiving party and used only for purposes of performing obligations hereunder. Confidential information shall not include information that is or becomes generally available to the public other than through breach of this Agreement, or information independently developed or rightfully received from a third party without restriction.

The receiving party may disclose confidential information as required by law or valid court order, provided that it gives prompt written notice to the disclosing party where permitted and reasonably cooperates in any lawful effort to limit the disclosure.

CERTIFICATIONS & AUTHORIZATIONS

By submitting this Request Form the Requesting Party certifies that to the best of its knowledge the information provided herein is true, accurate, and complete. The Requesting Party authorizes the Relief Provider and its agents to inspect affected premises, to review supporting documentation, and to obtain verification from third parties as necessary to substantiate losses and administration of relief funds.

The Requesting Party acknowledges that knowingly submitting false or misleading information in order to obtain relief is a violation of applicable law and may result in civil or criminal penalties, recovery of disbursed funds, and prohibition from future assistance.

I certify the information in this form is true and the supporting documents are accurate.

Photographs of damage    Repair or replacement estimate    Proof of ownership or occupancy
Insurance declarations or claims    Other (describe below)

GOVERNING LAW; ENTIRE AGREEMENT

This Request Form and Assistance Agreement shall be governed by and construed in accordance with the laws of the state specified by the Relief Provider below. Any dispute arising from this Agreement shall be resolved in the courts located in that state, except where federal jurisdiction applies.

This document, together with any attachments, schedules, and incorporated supporting documentation, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior proposals, negotiations, or agreements, whether written or oral. No amendment shall be effective unless in writing and executed by authorized representatives of both parties.

ADDITIONAL ADMINISTRATIVE INFORMATION

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