The Jack Gargalino Memorial Foundation Wounded Officer Application for Benefits

The Jack Gargalino Memorial Foundation First Responder Application for Benefits
Founded in 2022, the Jack Gargalino Memorial Foundation is a 501(c)(3) charity that provides direct financial support to first responders—military, police officers, firefighters, and EMTs—who are facing unexpected hardship due to injury, illness, or other life-altering events.

Qualifications:
- Legal resident of the United States
- A current or former first responder or the immediate family member (spouse, child or dependent) of a first responder
- Demonstrate a financial hardship due to:
  - A line-of-duty injury
  - A diagnosed medical condition (physical or mental)
  - A critical life event (e.g. natural disaster, loss of home, funeral costs, etc.)
*Persons may reapply for succeeding years
Officer Information
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Officer Employment
Agency
Assignment / Rank
Employment Date

MonthDayYear
Date
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse Information

If Applicable
Name

First NameLast Name
Phone Number

Area CodePhone Number
Date of Marriage

MonthDayYear
Date
Employer
Occupation
Annual Income
Dependent Information

If Applicable
Number of Dependents

I AFFIRM THAT ALL STATEMENTS I HAVE INDICATED HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY MISREPRESENTATION I HAVE MADE CAN CAUSE FOR THE INVALIDATION OF MY APPLICATION AND SHALL BAR ME FROM RE-APPLYING FOR THE SAME.
Applicant's Signature

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Name of Applicant

First NameLast Name
Date Signed by Applicant

MonthDayYear
Date
Phone Number

Area CodePhone Number
Should be Empty: