Greensboro Police Dependents' Fund Application

Greensboro Police Dependents' Fund Application
The Greensboro Police Dependents’ Fund was established to provide financial support to officers and their families during times of need. Funds are available to the dependents of officers who have died in the line of duty, become critically ill, or critically injured. In addition, sworn or retired officers who are critically injured or critically ill are also encouraged to apply. It is not required for the injury or illness to be job related to apply.

All distributions will be decided by the Greensboro Police Dependents Fund Board of Directors based on governing bylaws. To apply, please complete the form below.

Any questions should be directed to the Executive Officer of the Chief of Police at (336) 373-2450.

**PLEASE NOTE: Supporting documents, such as an invoice, proof of payment, valid ID, etc., will also be required as necessary to verify the dependent’s identity and expenses that qualify for assistance. These can be uploaded in the form below.

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.
Applicant Information
Full Name*

First NameLast Name
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Birth State*
Name of Greensboro Police Officer *

First NameLast Name
Relationship to Officer*
Employment Information
Place of Employment
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of Employment:
Please enter start date and end date, if applicable.
Grant Request Information
The Greensboro Police Department Foundation provides grants to support any dependent or dependents of any active or retired Greensboro Police Officer. Priority will be given to the dependents of those officers who have died or become disabled while in service or after treatment. In addition, active officers or the dependent(s) of an active officer who have been impacted by a critical illness are also eligible to apply for support.
Please provide a detailed statement explaining the reason for the request and how the funds will be used:*
Include college institutions or entities to be paid with Greensboro Police Dependent Funds.
Amount of Funds Requested:*
Scan and attach all supporting documents:*

Browse Files
Documents include valid ID, invoices, proof of payment, etc. Cancelof
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Greensboro Police Dependents' Fund Application

Applicant Information

Employment Information

Grant Request Information