City of Rancho Palos Verdes

2. 
4. NEIGHBORHOOD/HOA PUBLIC SAFETY REIMBURSEMENT PROGRAM APPLICATION
6. HOA or Neighborhood Name*
8. First Name of Applicant*
9. Last Name of Applicant*
11. Email Address of Applicant*
12. Phone Number of Applicant*
14. Alternate Name *
15. Alternate Phone Number*
16. Alternate Email Address*
20. Community Consensus Attestation
    Community Consensus Attestation for Neighborhoods and HOAs

    To demonstrate community consensus, neighbors may write or sign their name. If the project is within 50 feet of private property, the property owner (Adjacent Property Owner) should be notified of the proposed project. 

    The neighborhood should use its discretion in the numbers of signatures it should collect to demonstrate consensus and support for the project. 

    Applicant should consider receiving signatures from 40% of homeowners within the neighborhood. Utilize additional pages as needed. We, the undersigned, support the proposed public safety project. 

    If the undersigned is a member of the neighborhood (“Financial Contributor”), undersigned additionally agrees to be responsible for all equipment, service, and installation costs associated with the proposed project and agrees to all terms outlined by the City’s Public Safety Reimbursement Program, as signed by the Designated Representative.

21. This is my first time applying for a Public Safety Reimbursement*

    1. Yes
    2. No, my neighborhood has applied in a previous year.

    If you are a returning applicant, please complete the returning application page for expedited processing as funds are available. 

23. New applicants must upload the Attestation of Community Consensus form*
27. Neighborhood/HOA location information*

    Please provide a labled map indicating your neighborhood or HOA boundaries.

29. Number of households within your neighborhood or HOA*
30. Description of planned purchase*
32. Proposed Camera Location (s)*

    Please provide the cross streets and the cardinal directions.

33. Description of how this purchase will improve public safety
35. Vendor Name*

    Participants are encouraged to conduct their own due diligence in selecting a camera type and vendor.  

36. Total Cost

    Please enter the total cost excluding tax.

37. Requested Reimbursement

    Up to 50% of the cost for a neighborhood with a maximum reimbursement of $2000.

39. 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
40. If yes, please upload Receipt
41. Upload image of installed camera (s)
45. Terms and Conditions

    On behalf of the (Neighborhood) 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. As an authorized representative, 

    I acknowledge and agree to the following Program conditions on behalf of the Neighborhood as follows. 

47. Terms and Conditions (cont.)*

    1. The Neighborhood is the primary signature of the proposed purchase/service and the neighborhood is responsible for all equipment, service, installation, maintenance, and repair costs. Participation in the Program does not grant any exemptions from otherwise required permitting processes.
    2. The Neighborhood is responsible for insurance and indemnification of work.
    3. 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.
    4. 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.
    5. The Neighborhood agrees 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.
    6. The Neighborhood agrees that the funds received from this program will only be used as a reimbursement for the approved purchase.
    7. Once awarded, the Neighborhood shall not apply again for a neighborhood reimbursement of a public safety purchase.
    8. 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, including Attestation of Community Consensus (on next page) • Proof of Purchase • Proof of Project Completion (e.g., photo) • Permits/approvals (as required)
    9. 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.
51. 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.

53. Signature*

    1. I agree. Electronic signature
54. Signature
55. Date Submitted
    Date Submitted
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit Submit and Print

* indicates a required field