City of Rancho Palos Verdes

2. 
4. INDIVIDUAL PUBLIC SAFETY REIMBURSEMENT PROGRAM APPLICATION
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip*
15. Email Address*
16. Alternate Name and Number
20. This is my first time applying for a Public Safety Reimbursement*

    1. Yes
    2. No
21. I have already purchased a device which I am submitting for reimbursement*

    1. Yes, I have uploaded the receipt
    2. Yes, I will email the receipt
    3. No, I haven't purchased my device
22. If yes, please upload Receipt
26. Where will this device be located*

    Please indicate where on the property the device will be located (i.e. front door, front of garage, back yard, side gate, other).

27. Description of how the purchase will improve public safety*
29. Description of planned purchase*

    Please indicate the brand (i.e. Ring, Blink, Google Next, other). Participants are encouraged to conduct their own due diligence in selecting a camera type and vendor.  

30. Total Cost

    Please enter the total cost excluding tax

31. Requested Reimbursement

    Up to 50% of the cost, up to $100

33. Upload image of installed camera (s)
34. Upload image of installed camera (s)
38. Terms and Conditions

    By submitting this form, I agree to adhere to the City of Rancho Palos Verdes’ Public Safety Reimbursement Program (Program) terms, a copy of which are provided herein, and reviewed by me, including each of the conditions of all City issued permits issued in connection therewith. 

    I am the primary signature of the proposed purchase/service and I am responsible for all equipment, service, installation, maintenance, and repair costs. Participation in the Program does not grant any exemptions from otherwise required permitting processes. I am responsible for insurance and indemnification of work. 

    Compliance with the Program terms requires that the Los Angeles County Sheriff’s Department, by way of the Lomita Sheriff’s Station, be provided with access, review, and download of footage from the camera system for crime-prevention and investigation purposes. The City of Rancho Palos Verdes, its City Manager or their Designee, will be provided with access, review, and download of footage for crime prevention and investigation purposes. 

    Once awarded, I shall not apply again for an individual reimbursement of a public safety purchase. The following will be submitted as part of the application to the City of Rancho Palos Verdes. 

    Proof of Purchase and Completion will be required prior to disbursement of funds: • Project Application • Proof of Purchase • Proof of Project Completion (e.g. photo) • Permits/approvals (as required) In no event will the City of Rancho Palos Verdes be liable for any loss of data, property loss, damage, bodily injury, cost of recovery, or other special, incidental, consequential, indirect, punitive, exemplary or reliance damages arising from or in relation to this Agreement, however caused and regardless of theory of liability

40. Terms and Conditions (cont.)*

    1. I agree that the footage captured by the security camera system shall be utilized exclusively for crime-prevention or investigation purposes and shall not be utilized to capture interior images of homes or invade personal privacy.
    2. I agree that the funds received from this program will only be used as a reimbursement for the approved purchase. Once awarded, I shall not apply again for an individual reimbursement of a public safety purchase.
    3. I am the primary signature of the proposed purchase/service and I am responsible for all equipment, service, installation, maintenance, and repair costs. Participation in the Program does not grant any exemptions from otherwise required permitting processes. I am responsible for insurance and indemnification of work.
44. Signature and Date

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

46. Signature*

    1. I agree. Electronic signature
47. Signature
48. Date Submitted
    Date Submitted
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field