Officer Distress Fund Application
Applications for assistance may be submitted by any member of the Wisconsin State Lodge on their own behalf, on behalf of another member, or on behalf of non-members, including law enforcement officers and individuals working in related fields facing financial distress due to injury, illness, death, or other significant personal events. Preference and priority will be given to members of the Wisconsin State Lodge, and their immediate families. While we remain committed to assisting non-member law enforcement officers and individuals in related fields, our primary focus will always be on providing aid to our members and their families.
Requesting Party
Name
*
First Name
Last Name
Lodge
*
Lodge #
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Distress Fund Recipient
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Membership Status
*
Please Select
WI FOP Member
Family Member of WI FOP Member
Non-Member LEO
Family Member of Non-Member LEO
Non-LEO
Family Member of Non-LEO
Complete if Recipient is WI FOP Member
Lodge
Lodge #
Complete if Recipient is Family of WI FOP Member
Member Name
First Name
Last Name
Lodge
Lodge #
Member Relationship to Recipient
Complete if Recipient is Non-Member LEO
Agency
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Complete if Recipient is Family of Non-Member LEO
LEO Name
First Name
Last Name
Agency
Street Address
Street Address Line 2
City
State
Postal / Zip Code
LEO Relationship to Recipient
Complete if Recipient is Non-LEO/Family of Non-LEO
Describe Recipient or Family of Recipient’s Work/Involvement in Related Field
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Request Details
Describe Circumstances Leading to Request for Funds
*
Attach Any Relevant Files (Optional)
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Amount Requested
*
Description of What Funds Will be Used For
*
Distribution of Funds
How Should Funds be Distributed?
*
Check Mailed to Recipient at Address Provided
Electronic Payment Through Zelle at Email Provided
Direct Payment to Service Provider
Other
Complete if Direct Payment to Service Provider Selected
Business Name
Contact Person
First Name
Last Name
Contact Person Phone
Please enter a valid phone number.
Contact Person Email
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Service Provided
Account #/Invoice #
Attach Invoice
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Drag and drop files here
Choose a file
Cancel
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Submit
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