* I, _____, understand and accept the purpose of the humanitarian assistance as outlined in Layton City’s Humanitarian Policy. I acknowledge that any and all assistance extended by the City are intended to provide assistance for uninsurable losses.
I understand that Layton City has the right to conduct due diligence by contacting my homeowner insurance company to verify the absence of coverage. If coverage is found to be available, I understand that I will be responsible for paying the City in full for any assistance provided on my behalf that is not deemed an uninsured property loss. Additionally, any and all costs for services that may have been extended to me will be my sole responsibility. I acknowledge that failing to submit or include my homeowner insurance information may have consequences, potentially affecting the eligibility or amount of humanitarian assistance being extended on my behalf.
I affirm that I have been provided with the location of the Layton City Humanitarian Assistance Policy and that I have read and understood the guidelines for the issuance of humanitarian assistance. I also affirm that I personally experienced an uninsurable loss for which I am requesting humanitarian assistance. I understand that any misrepresentation of material fact regarding my homeowners insurance with the intention of obtaining benefits or payments can lead to legal consequences. Moreover, I am aware that it is illegal to receive both insurance payments or benefits and humanitarian assistance for the same property loss.
By submitting this form, I affirm under penalty of law that all the information provided herein is true and correct to the best of my knowledge. I understand that any misrepresentation or falsification of information may result in legal consequences and that I will bear full financial responsibility of any and all services extended on my behalf.