HxBIA Vandalism Grant Program Application for Assistance
File Number (assigned up approval)
Date
*
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Month
-
Day
Year
Date
Legal Business Name if different from Above (ie: Corporation Number)
*
Your Trade Name
*
Owners Name
*
First Name
Last Name
Business Address (Location where incident occured)
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Have you submitted a claim to HxBIA in the current calendar year?
*
Please Select
Yes
NO
Type of Vandalism
*
Please Select
Broken Windows
Etching on Windows
Doors/Frames
Brick/Work
Locks
Security Gates
Security Cameras
Other
If other write here
Date of Incident
*
-
Month
-
Day
Year
Date
Approximately time of incident. If after hours, or absent - your best guess
*
Hour Minutes
AM
PM
AM/PM Option
Describe in as much detail as possible what damage was done
*
Were the police called/notified? (Please note we require you to file a police report to receive funding. The non-emergency number is 604-717-3321. We know this takes time, but this provides vital statistics for crime and improved response in our area.)
*
Please Select
Yes
No
Will be Calling
Not going to call
If called, did police attend?
Please Select
Yes
No
Please provide a police file number
Please share with us the gist of the results of the police attending
What was the total cost of any repairs?
*
Did Insurance cover any of the cost of this repair?
Yes
No
If so, how much was your deductable?
Please add photos of damage, receipts for repairs, copy of related insurance claim(s), police reports or other information that will assist us to support your request for assistance.
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I hereby acknowledge that the information provide on this application is true and that the grant amount requested is not covered by my insurance or other programs.
Print Name
*
Signature
Todays Date
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Month
-
Day
Year
Date
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