The fLAWless Fundraiser Application

1
Application Requirements* This field is required.Please have the following handy prior to starting the application. Once started, application cannot be saved for later and once submitted, application cannot be edited. · Business Information: contact person, address, email, phone number · Proof of Damage: photos or videos of damage (if applicable) · Estimated Cost of Repairs (if applicable) · Estimated Cost to Replace or Order Inventory/Supplies · Proof of Insurance Claim Denial (if applicable): if you submitted an insurance claim, please provide proof of denial. · Proof of Expenses (if available): this can be quotes from contractors, vendor invoices, etc. · 30-60 second: please provide a 30-60 second video about your business and how this fund will help you build or rebuild.
2
Contact Person* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Area Code
Phone Number
5
Business Name* This field is required.
6
Physical Business Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Business Type* This field is required.
Retail Location
Salon/Spa
Studio/Showroom
Other
8
Estimated Cost of Damage/Loss* This field is required.If no damage, put $0.
9
Estimated Cost to Replace or Order Inventory/Supplies* This field is required.
10
Social Media Handles* This field is required.Put "N/A" if not applicable.
Instagram
Twitter
Facebook
11
Proof of Damage/LossPlease upload photos of damage.
Drag and drop files here
Select files to upload
Cancelof
12
Fund Use* This field is required.Please provide a brief description of the damage and how funds will be used if awarded.
Huge
Large
Normal
Small
Ok
Ok
13
ExpensesPlease provide any proof of repair/replacement costs. This can be invoices from contractors, suppliers, vendors, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Video Upload* This field is required.Please provide a 30-60 second video about your business and how this fund will help you build/rebuild. If selected as a recipient, both Law and Rebuild the Hood will post to announce you as an award recipient and help promote your business.
Drag and drop files here
Select files to upload
Cancelof
15
Did you have insurance?* This field is required.
YESNO or N/A
16
No Insurance* This field is required.Please explain the lack of or gap in insurance coverage. If not requesting funds for damages, please input N/A.
Huge
Large
Normal
Small
Ok
Ok
17
Have you filed a claim?* This field is required.
YESNO
18
Was your claim denied?* This field is required.
YESNO
19
Proof of Claim Denial* This field is required.Please upload proof of a denied insurance claim.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Calculation
21
Disbursement* This field is required.If you are awarded a grant, where should funds be disbursed?
Bank Name
Please Select
Please Select
Business Checking
Business Saving
Money Market Account
Other
Account Type
22
Account Number* This field is required.
23
Verify Account Number* This field is required.
24
Routing Number* This field is required.
25
Verify Routing Number* This field is required.
26
Deposit Authorization* This field is required.
27
Signature* This field is required.By signing below, you acknowledge that you are the owner of the business referenced above and/or are an agent or officer authorized to make decisions on behalf of the business. You also acknowledge that you are a Black owned, registered entity in the state of Illinois with all necessary licenses and requirements to operate in the state and the city of Chicago. Further, you acknowledge that you own the rights to any photos provided and grant Luxury Law and Rebuild the Hood irrevocable rights to use the photos as well as name and likeness of the business on the web and across social media channels to highlight how donations from the fund were used, if awarded. Finally, you acknowledge and understand that submitting this application does not automatically qualify you as an award recipient.
Clear
Should be Empty: