GCVFA/GCVFALA Fire Assistance Fund

GCVFA/GCVFALA Fire Assistance Fund
Greene County Volunteer Firemen's Association and Ladies Auxiliary

Fire Assistance Fund

This form must be submitted by the fire chief of the company / department / district where there has been a fire, to qualify the victim for assistance.
Date of loss:*

MonthDayYear
Date
Name of person who suffered a loss:*

First NameLast Name
Contact information:*
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Location of fire:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fire company/department/district: *
Cause of fire:*
Type I've lost:*

Total lossRoom and content fireSmoke and water damage
Any injuries:*

YesNo
Describe loss*
In the case of a fatality, who should be contacted:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fire Chiefs name:*

First NameLast Name
Fire Chief's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Signature*
Date*

MonthDayYear
Date
Treasure use only:
Assistant amount:
Check number:
Assistant type:
Date of assistant:

MonthDayYear
Date
Should be Empty: