Cleveland County Individual Safe Room Voluntary Participation Form

	*If your home is located in a flood zone you may not apply for participation. Please call (405)366-0200 for more information.*
*	Homeowners Name
*	Property Address
	- Address
	- City
	- Zip Code
*	Mailing Address
	- Address
	- City
	- Zip Code
*	Home Phone
*	Cell Phone
*	What year was your home built
*	What type of Safe Room are you considering?	Above Ground Below Ground
*	Will your Safe Room be installed within 100 feet of the home's foundation?	Yes No
*	If No,why?
*	Is your home located in a historic district?	Yes No
	If your home was built before 1890, if it is located in a historic district, or you will install the safe room further than 100 feet from the foundation, you will have to complete additional paperwork. Please call (405)366-0200 for further information.
*	I, , certify that I am the owner of the above described property and that it is my primary residence. I agree to comply with criteria and guidelines for the Safe Room Rebate Incentive Program. I understand that this is a reimbursement program approved by the Federal Emergency Management Agency and that, as the applicant, I am required to complete my financial obligation to my Safe Room Contractor prior to seeking reimbursement from Cleveland County. I understand that the local share of 25% is my responsibility. I as the applicant will receive reimbursement from Cleveland County for 75% of the cost of my safe room up to the maximum amount of $2500.00 upon receipt by Cleveland County of funds from FEMA. Cleveland County will have no obligation of reimbursement to the applicant if for any reason funds are not received from FEMA. A contractual obligation between me and Cleveland County does not exist until I have been notified of my acceptance into the Individual Safe Room Rebate Program. I will not initiate a contract for installation of my safe room, under this program, before I have been notified by Cleveland County that this program has been approved by the Federal Emergency Management Agency and that I have been Okayed to begin installing my safe room. I understand that as the homeowner I will be responsible for any and all maintenance or repairs to my safe room. I understand that I am responsible for making sure my safe room meets or exceeds FEMA 320 Standards and I have a signed, notarized statement from my Safe Room Contractor stating such. Once I have been notified that it is okay to install my safe room, I will send a Progress Report to Cleveland County Program Manager every 90 days until my safe room has been installed, paid for, and I have received reimbursement. I understand my Safe Room must be installed within (9) nine months of notification of approval or my application will forfeit and an alternate will be chosen in my place.
*	eSignature: