Key West Police Department Love Fund Financial Assistance Application

Key West Police Department Love Fund Financial Assistance Application

Please complete a detailed financial assistance application form including personal information, income details, and reason for assistance. Please, also, upload required supporting documents.
**PLEASE NOTE**

The KWPD Love Fund requires asset verification. This is to ensure all members are transparent and assistance is given to those only in need. All information in your application is kept confidential. Please upload a copy of your current CHECKING ACCOUNT STATEMENT or BANK ACCOUNT BALANCE -a screenshot is acceptable.

PLEASE DO NOT INCLUDE OR ALLOW ACCOUNT NUMBERS OR SS# IN YOUR ATTACHMENTS
KWPD Member Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Street Address (include apartment or lot#)

Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What is your work status?

Working Full TimeWorking Part TimeOtherOut on Medical Leave (FMLA) for self or family memberWorkers Compensation Leave
Monthly Income (USD)
Amount of Assistance Requested?
Please list reason for financial assistance:

Estimated monthly income earned from working off duty details?
Estimated Monthly Income from working overtime?
Monthly mortgage/rent payment (including escrow)
Automobile payment #1
Automobile Payment #2
Boat/Luxury Item monthly payment
Monthly childcare expenses
Total utilities expenses
Monthly grocery expenditures
Child support monthly expense
Other expense
Other expense
Other expense
Other expense
Other expense
Other expense

Marital Status
If you selected "Married", Please enter your spouses total monthly income
Spouse monthly income source

Please upload your most recent paystubs and banking statement here.

Cancelof
Do you have City of Key West supplemental AFLAC insurance?
If you have AFLAC insurance, have you submitted a claim?
Do you know the dollar amount your claim is eligible for?

DISCLAIMERS:

CONFIDENTIAL: This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error, please notify the system manager. This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail. Please notify the sender immediately by e-mail if you have received this e-mail by mistake and delete this e-mail from your system. If you are not the intended recipient you are notified that disclosing, copying, distributing or taking any action in reliance on the contents of this information is strictly prohibited.
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Thank you for applying for financial assistance with the Key West Police Love Fund. Please read, complete, and sign the following form for your application to be considered.

As an applicant, I release and hold harmless the Key West Police Department Love Fund and their Executive Board Members, Board Members and Volunteers from any and all claims, costs, suits, actions, judgments or expenses upon any damage or finanicial loss or injury to me or to my property which may arise from this application.

I acknowledge that the Executive Board Members and Board Members are uncompensated volunteers, which I agree to hold harmless, whether or not my assistance application is approved and I receive a monetary grant/assistance as a result.

I acknowledge that there is no bias in approving applications for assistance and that not all applications for assistance are approved. Applications are approved and vote on by a majority vote of Executive Board Members and Board Members and are not the decision of one individual as a whole.

I acknowledge that applications are not approved and grants are not distributed based on race, creed, sexual orientation, gender identity, age, familial status, disability or religion, or any other protected class; but rather, are approved based financial need.

I acknowledge that funds from The Key West Police Department Love Fund are only eligible to KWPD Department members.

In signing below, I acknowledge that I have read and understand this agreement and if a dispute arises, I agree to 3rd party mediation versus legal court action.
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Date

MonthDayYear
Date
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