Disaster Recovery Centre Tel.

: 902-424- 5620 and 1-866-424-5620

P. O. Box 2581 Fax: 902-424-5376
Halifax, NS B3J 3N5

Website: http://emo.gov.ns.ca/content/about-emo

Application for Disaster Financial Assistance (DFA)
September 9
th
11
th
, 2012 Floods

SMALL BUSINESS

Deadline: Apply by December 10, 2012

Section 1: Eligibility

1. Assistance is limited to Cumberland; Colchester; Hants; and Pictou counties and Halifax
Regional Municipality (HRM).

Please read the following statements and check which applies to you:

Check here to confirm that your business is located in one of the areas affected. Go on to
question 2.

If your business is NOT located in one of the areas indicated above, you are NOT eligible
for assistance because assistance is limited to the effected areas listed above . DO NOT
complete a DFA application.

2. Are you insured for the damage being claimed? (If you are not certain whether insurance covers
your loss, then contact your insurance company).

Check here if you are not insured. Go on to question 4.

Check here if you are insured. Go on to number 3.

3. DFA only covers uninsurable losses. An insurable loss is one for which insurance coverage is
readily available. Since you have insurance against your loss, you must submit a claim for your loss to
your insurance company. Do not complete a DFA application.

4. Could you have obtained insurance for the loss, even if you chose not to purchase it?

Check here to confirm that you could not have obtained insurance. You must attach a
denial letter from your insurance company. Go on to Question 5.

Check here to confirm that you could have obtained insurance. Since you could have
obtained insurance, you are NOT eligible for DFA. Do not complete a DFA application.


Page 1 of 3

5. Is the property owned by the business?

Check here to confirm that the business owns the property. Go on to question 6.

Check here to confirm that you rent or lease the property AND that you have attached a
copy of the rental agreement for this property. Go on to question 6.

6. Are you the sole proprietor and full-time, day-to-day manager of the business?

Check here to confirm that you are the sole proprietor and full-time, day-to-day manager of
the business and you have attached a certified copy of the Nova Scotia Registry of J oint Stock
record for your business and a certified copy of the companys share registry or a letter from
your lawyer verifying you are the sole proprietor or owner of greater than 50% of the business.

Go on to question 8.

Otherwise, go on to question 7.

7. Is the business a partnership?

Check here to confirm that you have attached a copy of the partnership agreement showing
that you are the owner of greater than 50% of the business. Go on to question 8.

8. Is your gross revenue from this business not less than $10,000 and not more than $2,000,000?

Yes, the business generates a yearly gross revenue as reported for income tax purposes of
not less than $10,000 and not more than $2,000,000. Go on to Section 2.

No, the business, does not generate a yearly gross revenue as reported for income tax
purposes of not less than $10,000 and not more than $2,000,000 it is not eligible for
DFA. Do not complete a DFA application.

Section 2: Applicant Information - Please fill in the details about yourself and the type of damage.


Business Owner(s)
and Share Structure:


Business Name:

Civic Address:

Community: Postal Code:
Mailing Address:
(if different)

Postal Code:
Telephone: Work: Fax:
E-mail:

Page 2 of 3
Name of insurance company, policy
number (if applicable):
Agents name and telephone number:

Please describe the affected property:






9. Please describe the damage at this property. Attach additional pages if necessary, and include
photographs.


Damage
Description:





10. You MUST complete the attached Schedule of Loss. Include written estimates or copies of
invoices for any work that has been done or will be done.

Check here when you have completed the Schedule of Loss.


I/we, with the submission of this application for assistance, authorize and agree to permit, with
reasonable notice of not less than 24 hours, an independent adjustor appointed by the Emergency
Management Office to inspect the property which is the subject of this application for assistance and
examine appropriate related insurance coverage and also consent to such other examination of
relevant records maintained by provincial or federal government departments for verification of
information respecting this application.


DECLARATION: I/we, _________________________________________ declare as follows:

1. That I/we am/are the owner(s) of the business named in the foregoing application.

2. That the damages described arise from and were caused by the declared disaster event.

3. That all the statements contained in this application are true, and that I/we have not concealed or
omitted any information required to be given.

4. That I/we make this declaration conscientiously believing it to be true and knowing that it is of the
same force and effect as if made under oath and by virtue of the Canada Evidence Act.

Declared in the Province of Nova Scotia, this _____(day) of ________(month), _______(year).

Company Name: ______________________ Per: _________________________________

_____________________________________ ____________________________________
Applicant Signature Co-applicant Signature



Page 3 of 3


SCHEDULE OF LOSS

Small Business: Application for Disaster Financial Assistance
(DFA)

Business Name: ____________________________
Owners Name (s): ___________________________________

IMPORTANT- Make sure you attach a written estimate for the replacement item, or a copy of a paid
invoice. Your application will be returned if you do not include this information.

Itemized description of damage or loss:
Any request for assistance shall be subject to a deductible amount
of $1,000.00. Applications for losses of less than $1,000.00 will not
be accepted or considered.
Replacement
cost estimate
(attach estimate
or paid invoice):
Amount
claimed:





















Application for Disaster Financial Assistance (DFA) Checklist

Small Business
Business Name: ____________________
Owners Name (s): ___________________________________

Are the properties (Building/Chattels/Inventory) owned by the company?
(Copies of Financial Statements are required to support the claim.)

Have you included:

Yes A completed Small Business Application for Assistance?

Yes Confirmation you own greater than 50% of the business or a copy of the partnership?

Yes Confirmation that the business generates yearly gross revenue as reported for income
tax purposes of not less than $10,000 and not more than $2,000,000?

Yes A completed copy of the required Schedule of Loss?

In order to prevent a possible substantial delay in the processing of your application,
please ensure that all of the above listed requirements are included.

Yes No - Have you included a letter from your insurance company confirming the damage is not
_______ _ insurable. If not yet available, it can be submitted later by either yourself or your insurer.

Yes No - Have you included your insurance company agents name and telephone number?

Yes No - Are any cost estimates or paid invoices attached to the Schedule of Loss?

Yes No - Are copies of any available photographs, both before and after disaster, included?


The Program:

Disaster Financial Assistance (DFA) programs are designed to help municipalities, individuals,
farmers, small businesses, and non-profit organizations recover after a disaster. DFA does not
cover the cost of all losses and damages to property resulting from the disaster. DFA programs are
intended to cover the costs of restoring properties to their pre-disaster conditions.

DFA is not intended to be an alternative or a substitute for adequate insurance coverage.

For further information, please see our web site at: http://emo.gov.ns.ca/content/about-emo ,
or contact us at the:
Disaster Recovery Centre Tel.: 902-424-5620 or 1-866-424-5620
P. O. Box 2581 Fax: 902-424
Halifax, NS B3J 3N5