Personal Information

Individual ID:
(If necessary, please contact CTA Membership Department at (650) 552-5278 or membership@cta.org for your 10-digit CTA ID number.)

* Date of Loss or Displacement:

(The filing deadline is 12 months from the date of the incident.)

* First Name:

* Last Name:

* Address 1:

Address 2:

* City:

* State:

* Zip:

* Email Address:

* Phone Number:

Work Phone:

Employment Information

School District:

Date Of Hire:

Job Title:

Building Site:

Local Information

Local Chapter:

Local Assn Leader Or PCS:

Local Phone:

Local Email:

Attachments

(attach required documents for each Grant requested)

File List:

*

Grant Request Information and Qualification

(Please check all that apply)

STANDARD GRANT

$ - Standard Grant - Please provide amount requested (up to $1,500) of your significant economic hardship.

Damage exceeds 5% of replacement cost of primary residence (Attachments Required: insurance adjuster’s written estimate required)
Access to primary residence prohibited for 15 days by the City or County (Attachments Required: documentation showing access to primary residence was prohibited by City or County for at least 15 days: declared unsafe to occupy, mandatory evacuation orders or other AND receipts, credit card statement or other documents, including dates, to substantiate actual loss or spending)
Start Date: End Date:

No utilities (gas, electricity or water) for at least 15 days? (Attachments Required: letter from the utilities provider, utility statement or other)
Start Date: End Date:

Damage to affixed property, land or structure within the primary residence property line? A grant up to $500 grant may be available. This applies for date of loss effective January 1, 2023. (Attachments: substantiation of losses or written estimates)

CATASTROPHIC DAMAGE GRANT

$ - Catastrophic Damage Grant - Please provide amount requested (up to $1,500) of your significant economic hardship. Attach substantiation of damages to primary residence in excess of $50,000. If you experienced a total loss of your primary residence, please include with this application a picture or evidence to substantiate loss once determined. Note: Qualification and approval for the Standard Grant is one of the requirements for consideration of the Catastrophic Damage Grant. Application for the Standard and Catastrophic Grants may be made concurrently.

Damage exceeds $50,000 (Attachments Required: insurance adjuster's written estimate required)
Total loss of residence (Attachments Required: proof required: insurance adjuster's total loss statement, pictures or other)

TEMPORARY DISPLACEMENT GRANT

$ - Temporary Displacement Grant - Please provide amount requested (up to $500). Application for Temporary Displacement Grant, and Standard and/or Catastrophic Grants may NOT be made concurrently.

Mandatory Evacuation/access prohibited by City or County/Official road closures. Road closures applies for date of loss effective January 1, 2023. (Attachments Required: documentation showing access to primary residence prohibited by City or County as mandatory restriction for at least 5 days: declared unsafe to occupy, mandatory evacuation orders or other, AND receipts, credit card statement or other documents, including dates, to substantiate actual loss or spending)
Start Date: End Date:
No utilities (gas, electricity or water) for at least 5 days? This applies for date of loss effective January 1, 2023. (Attachments: letter from the utilities provider, utility statement or other, AND receipts, credit card statement or other documents, including dates, to substantiate actual loss or spending)
Start Date: End Date:

SHORT TERM DISPLACEMENT GRANT (For date of loss effective November 18, 2021)

$ - Short Term Displacement Grant - Please provide amount requested (up to $1,000).
Application for Short Term Displacement Grant and Standard and/or Catastrophic Grants may NOT be made concurrently. Members eligible for the Short Term Displacement Grant will NOT qualify for the Temporary Displacement Grant.

Mandatory Evacuation/access prohibited (Attachments Required: documentation showing access to primary residence prohibited by City or County for at least 10 days: declared unsafe to occupy, mandatory evacuation orders or other, AND receipts, credit card statement or other documents, including dates, to substantiate actual loss or spending)
Start Date: End Date:

No utilities (gas, electricity or water) for at least 10 days? (Attachments Required: letter from the utilities provider, utility statement or other, AND receipts, credit card statement or other documents, including dates, to substantiate actual loss or spending)
Start Date: End Date:

SCHOOL SITE GRANT

$

- School Site Grant - Please provide amount requested (up to $500). This Grant is to help a CTA member who has experienced personal losses at their damaged school site. (Attachments Required: itemized list of personal losses AND value of each item in classroom or school site stemming from damages caused by a disaster required).

Describe Your Loss and/or economic hardship to help substantiate grant critera

Send Payment To:

* Address 1:

Address 2:

* City:

* State:

* Zip:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I further understand that I will be responsible for any federal, state or local tax liability that may be associated with the grant upon approval and acceptance. Please contact the CTA Member Benefits Department if you do not receive a confirmation of receipt within 7 business days. Names and contact information for grant recipients may be shared with a grantee's local union representative(s) and/or CTA representative(s).