Loss Mitigation Grant Application

Supporting Safe Environments for Catholic Parishes, Schools, and Ministries

Required fields are marked with a *

Applicant Information

Unit information

Unit name* Unit no.* Address City State Zip code

Contact person for project

Contact name* Title Phone* Email

Hazard Information

Hazard details

Please describe the hazard* Please include the location of the hazard, issue, and how it creates a slip, trip, fall, or property damage risk. Attach photo(s) if available.

Image files only. Maximum image size is 10MB.

How was the hazard identified?

Check all that apply.

MCC Loss Prevention Representative inspection Staff observation Visitor report Other If ‘Other,’ please describe Date hazard was identified

Has the hazard resulted in previous incidents or near misses?*

No Yes

If ‘Yes,’ please describe

Project Details

Proposed remedy and scope of work

Please describe the proposed remedy* Attach contractor quote(s) if available.

Word, Excel, PDF, and image files only. Maximum file size is 10MB. Estimated project cost* Start date Completion date

Funding Request

Funding details

Amount requested* Amount requested can be no more than the maximum allowed by the program. Additional funds to be contributed by the unit, if any

Financial statement

Attach the unit’s current financial statement

Word, Excel, PDF, and image files only. Maximum file size is 10MB.

Certification

By submitting this application, I certify that:

The information in this application is accurate.
The grant funds will only be used for the purposes stated.
The unit agrees to submit documentation after project completion.

Name* Title* Date*