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Dominguez Incident Reimbursement and Assistance Application


As we work to mitigate impacts to the community following the Dominguez Channel incident of October 2021, and in an effort to assist in
improving quality of life while we address the underlying causes of the incident, we are offering three options, noted below. If you need
assistance with this application, please call 211, the County Help Line.

Note: Residents may select to either be reimbursed by the County for an item (Reimbursement), or have the County directly
provide that item to them (Direct Assistance), but not both.

UPDATE: Reimbursement offers have been extended to December 3, 2021.
To be eligible, you must live in the areas of Carson, West Carson, or the surrounding vicinity, and you must be experiencing odors
inside your home and/or you or someone in your household must be experiencing one or more of the following symptoms as a result of
the odors emanating from the Dominguez Channel: headaches and irritation in the eyes, nose, throat, and lungs. These symptoms
may be accompanied by dizziness, nausea/vomiting or abdominal discomfort. These symptoms should be short-term and typically
resolve when the odor goes away or when the person is in an area where the odors are not present. Symptoms can be worse in
people with pre-existing lung or heart conditions, such as asthma, COPD, or heart disease.

Residents affected by the Dominguez Incident that live outside of Carson and West Carson and the surrounding area are encouraged
to submit forms. Requests will be evaluated on a case-by-case basis.


Process for Reimbursement Program:
1. Complete and submit this form. All fields must be completed accurately and in full as indicated.
2. The County will review your application.
3. If you meet the criteria by living in the area and are experiencing symptoms, you will receive a notification email from the County that
your eligibility request has been approved. If we need additional information, we will contact you.
4. Once your eligibility request has been approved, you may proceed with the option you selected. Please remember to collect documentation,
to verify your expenses and submit that documentation to the County no later than December 16, 2021.** Anticipate reimbursement
approximately 3-5 weeks after the County's receipt of your complete and accurate submission of the required documentation. Inaccurate, incomplete,
or falsified submissions may result in delays or decline of your reimbursement.

*Denotes a required field.

**Please keep your receipts. A reimbursement form and additional guidance on required documentation is forthcoming. You will be required to
confirm you live at the address provided in your application by providing a copy of a recent utility bill, or a copy of a valid state issued ID
with your address, or other appropriate documents.

***Duplicate applications will result in previous applications under the same name, email address, and/or street address potentially being voided.
Incomplete applications will unfortunately be declined, and you will have to submit again. The most recent and complete application is the
one that will be evaluated for reimbursement.

Option 1 - For homes with heating and air conditioning systems, the County will reimburse or assist households (For assistance, please indicate
using the check box for Direct Assistance below) for filter inserts for those systems that are HEPA rated with activated carbon or other filters
recommended by the County Department of Public Health. The limit of reimbursement will be $60 per unit per household. Purchases must be made
from October 4, 2021 through December 3, 2021, unless otherwise extended in writing by Los Angeles County Public Works. Please see the release
below for additional details.

Option 2 - The County will reimburse or assist households (For assistance, please indicate using the check box for Direct Assistance below) for
air purifiers units if they don't already have them. For this purpose, air purifiers units mean any HEPA filtration system that utilizes
activated carbon, or other filtration system recommended by the County Department of Public Health. The limit of reimbursement is $400 per
household for homes 1,000 square feet or smaller and a $800 per household for homes above 1,000 square feet. Purchases must be made from
October 4, 2021, through December 3, 2021, unless otherwise extended by Los Angeles County Public Works. Please see the release below for
additional details.

Option 3 - The County will reimburse or assist the household (For assistance, please indicate using the check box for Direct Assistance below) for
one hotel room in Los Angeles County, up to $182 per day, and hotel self-parking for one vehicle per day. Meals, groceries, and miscellaneous
expenses will also be reimbursed at the rate of $66 per day for each person currently residing full time in the household who have been
relocated to the hotel. Receipts will be required for the hotel and parking. This offer is valid from October 4, 2021, through
November 26, 2021 (hotel checkout the morning of November 26, 2021). Reimbursements for hotel stays past the November 26, 2021,
checkout date will not be processed.

Please see the release below for additional details.

Please be advised when you and your household members are guests at the hotel you are obligated to follow all rules and policies
of the hotel. If you are asked to leave the hotel because you or a household member has violated the hotel's rules or policies,
the County will not provide new hotel accommodations. Additionally, if the hotels assess fees or charges for extraordinary cleaning or
damage to the room occupied by you and your household members, these fees or charges may be deducted from any reimbursement for daily
miscellaneous expenses that you request.


Which option are you requesting for reimbursement? * (Select only one)

Email:
*

Full name:
*

Home address, including city, zip code, and unit number (if applicable):
*

What is the best phone number to reach you?
*

If selecting Option 2, what is the approximate square footage of your home or apartment? *

If selecting Option 3, please provide the full name of each person currently residing full time in your household (including yourself)
intending to temporarily relocate. This will determine your maximum per diem amount for meals and incidentals.

Are you experiencing special circumstances not covered by these options and need to speak to a County representative about your situation (Yes/No)?
Are you or anybody in your household experiencing headaches and irritation in the eyes, nose, throat, and lungs, dizziness, nausea/vomiting or abdominal
discomfort as a result of the odors from the Dominguez Channel (Yes/No)? *

Are you experiencing odors in your home from the Dominguez Channel (Yes/No)? *

By checking the box below, I certify, under penalty of perjury under the laws of the State of California, that all of the information provided above is true and correct.
I Agree*

Process for Direct Assistance:

By checking the box below, I am requesting an item be provided to me by the County, as I am unable to obtain the item myself.

I need direct assistance

By checking the box below, I acknowledge that I have read the applicable release of liability below, for the option chosen above and agree to the terms of the release.

OPTION 1 and 2:
In consideration of receipt of reimbursement specified in for filter insert or air purifier units (collectively, "Units"), including any
installation of those Units, I do hereby release and forever discharge the COUNTY OF LOS ANGELES, the LOS ANGELES COUNTY FLOOD CONTROL DISTRICT
and their boards, officers, agents, servants, and employees from any and all claims and causes of action which I now may have, or may hereafter have,
on account of any injury and/or damage related to the receipt, installation and/or use of the Units. This release does not apply to any injury and/or
damage caused by the odors emanating from the Dominguez Channel.

I Agree*

INTERNAL USE ONLY

Investigator's Initial:
Status:
Reason for status:

Comments:
* Denotes required field.

Please don't change the next two fields.


Confirmation Email

 
Email address*
Re-enter email address*

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