GRANT APPLICATION

Individual Requesting Assistance

First NameMiddle NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

The intended beneficiary, if different than the individual listed above

First NameMiddle NameLast Name

Intended beneficiary's relationship to Fallen Officer

Fallen Officer's Name

First NameMiddle NameLast Name

Fallen Officer's Department

Badge Number

Date of Officer's passing

Date

Department's Chief of Police's Full Name

Chief of Police's Phone Number

Fallen Officer's number of law enforcement service years

Number of minor children supported by the Fallen Officer

Was the Fallen Officer the sole income provider?

If "no", is the spouse/domestic partner currently working?

How many of the following individuals relied on the Fallen Officer as their primary support?

Rows	Number of Individuals
Minor Children
Adult Children
Parent
Spouse/Domestic Partner

Is the Fallen Officer vested in a pension plan?

If "yes", please disclose how much is received monthly, the start of the payments and the duration of such.

As of the date of this application, is the Fallen Officer's net worth greater than $100,000? "Net Worth" is defined as cash, investments, retirement plans less debts. For homeowners,exclude the value of your home and the related mortgage from your net worth calculation.

For home owners, as of the date of this application:

Rows	Dollar Amount
What is the monthly mortgage payment?
What is the mortgage loan balance?

Do you anticipate receiving funds from any source in the next three (3) years?

If "yes", please explain.

Type of assistance:

Estimated amount needed:

Briefly describe the nature of your hardship and the circumstances supporting your request for assistance.

Has the intended beneficiary received or will the intended beneficiary receive any other assistance to meet this need?

If "yes", please disclose how much assistance has or will be provided and the duration of such.

Does the state in which the Fallen Officer died provide any financial assistance?

If "yes", please describe.

How did you learn about this grant?

If referral source is an individual, please provide the following information:

First NameMiddle NameLast Name

Referral Source Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referral Source Phone:

Please enter a valid phone number.Format: (000) 000-0000.

I affirm all of the information contained herein that I have given in order to qualify for this grant is truthful, complete, and correct to the best of my knowledge. I understand that I will not be considered if any of the above information is false. Furthermore, I understand and agree to repay any assistance that is obtained if such assistance was based on false or incomplete information submitted herein.

I understand that the Fallen Officer's Chief of Police may be contacted and asked to provide a statement of the Fallen Officer's good standing with the department.

Upon request, I agree to provide the Organization with evidence of the information, including financial documents such as bank statements, contained on this application. I understand that this application becomes the property of the organization when submitted.

Finally, if selected for a grant, I agree to provide the Organization with receipts and other requested documentation supporting that the grant dollars were used for the intended purpose consistent with the grant.

Signature

Section 1: General Information

Section 2: Financial Information

Section 3: Assistance Request

Section 5: Affirmation